Application Form - LDANR School-Year Programs Step 1 of 9 11% *****PLEASE NOTE: The LDANR has made the decision to keep all Fall programming online to ensure the safety of our clients, staff, and volunteers at this time. While we understand that in-person services are often preferred, we are working to provide services that can continue to promote growth and learning during these unprecedented times. *****To complete the LDANR program application form, it is suggested that you have a copy of your child's report card handy. To apply to our programming, please complete the following steps: Fully complete each question on our application form and click submit (please note: you cannot save). Submit supporting documents. The application is NOT CONSIDERED COMPLETE until your child's most recent report card/progress report has been received. Supporting documentation may include: - most recent report card OR progress report (*required); - Individual Education Plan (*required, if applicable); - Assessments (if applicable); - Teacher Feedback Form (if possible - Click Here for the Teacher Feedback Form); - Any additional information that you feel may be useful in determining your child's needs for the program. Following screening, accepted applicants will be notified closer to the program start date. Following acceptance, program payment will be required. This will be outlined in the acceptance email. Subsidy and payment plans may be available. Please note: This information will be kept strictly confidential. It will only be shared with LDANR staff and volunteers who will be working with the children. LDANR programs are designed for individuals with learning disabilities, not other exceptionalities. If unsure of eligibility, contact the office prior to completing the form at info@Ldaniagara.org.Has your child participated in LDANR programming previously?* Yes No Most Recent Program(s) Season/Year How did you hear about the LDANR?* Flyer/Brochure Friend/Family Member LDANR Communication (email, website, etc.) Your school/teacher Which program are you applying for today?* Online B.E.S.T. Program (Grades 3-5) Online Reading Rocks Program (Grades 1-8) Online JUMP Math Program (Grades 1-8) Online SOAR Secondary Program (Grades 7-8) Online SOAR Post-Secondary Program (Grades 11-12) BEST Program Schedule*Please note: The B.E.S.T. Program only runs on Wednesday evenings. Please click the box below to indicate that your child is available to attend B.E.S.T. on Wednesday evenings. I confirm my child is available Wednesday evenings for the B.E.S.T. Program SOAR Secondary Program Schedule*Please note: The SOAR Secondary Program only runs on Tuesday evenings. Please click the box below to indicate that your child is available to attend SOAR Secondary on Tuesday evenings. I confirm my child is available Tuesday evenings for the SOAR Secondary Program. SOAR Post-Secondary Program Schedule*Please note: The SOAR Secondary Program only runs on Thursday evenings. Please click the box below to indicate that your child is available to attend SOAR Post-Secondary on Thursday evenings. I confirm my child is available Thursday evenings for the SOAR Post-Secondary Program. Please select the days of the week that you would like your child to attend program.*Please note: Program participants are only able to participate in the Monday/Wednesday session or Tuesday/Thursday session, not both. Mondays & Wednesdays Tuesdays & Thursdays No preference Please note, the LDANR's primary form of communication with parents is through email. Caregiver 1 Name (Primary Contact for LDANR Communication)* Mr.Mrs.MissMs.Dr.Prof.Rev.None Title First Name Last Name Caregiver 1 Email (Primary Contact for LDANR Communication)* Caregiver 1 Phone Number (Primary Contact for LDANR Communication)*Address* Street Address City Postal Code Municipality*If you are unsure which Niagara municipality you are located in, please refer to the section below. Fort ErieGrimsbyLincolnNiagara FallsNiagara on the LakePelhamPort ColborneSt CatharinesThoroldWainfleetWellandWest LincolnOther: Please SpecifyPlease Specify:* Municipality of Fort Erie: Cities include Crystal Beach, Fort Erie, Ridgeway, Stevensville Municipality of Grimsby: Cities include Grimsby Municipality of Lincoln: Cities include Beamsville, Campden, Jordan Station, Vineland, Vineland Station Municipality of Niagara Falls: Cities include Niagara Falls Municipality of Niagara on the Lake: Cities include Niagara on the Lake, Queenston, St. Davids, Virgil Municipality of Pelham: Cities include Fenwick, Fonthill, Ridgeville Municipality of Port Colborne: Cities include Port Colborne, Sherkston Municipality of St Catharines: Cities include St Catharines Municipality of Thorold: Cities include Allanburg, Port Robinson, Thorold Municipality of Wainfleet: Cities include Wainfleet, Lowbanks Municipality of Welland: Cities include Welland Municipality of West Lincoln: Cities include Binbrook, Caistor Centre, Canfield, Grassie, Smithville, St. Anns, Wellandport Caregiver 2 Name Mr.Mrs.MissMs.Dr.Prof.Rev.None Title First Name Last Name Caregiver 2 Email (If different than primary email) Caregiver 2 Phone Number (If different than primary phone number)Member Status* Non-Member Current Member Who does the child primarily reside with?* Who has custody of the child?* Who will be picking-up/dropping-off the child?* Caregiver 1 Caregiver 2 Other(s) Name of Other Pick-Up/Drop-Off Contact(s)* Phone Number of Other Pick-Up/Drop-Off Contact(s)* Participant's Name* First Last Participant's Gender Female Male Non-Binary Birth Date (dd/mm/yyyy)* DD slash MM slash YYYY Age* Grade* School Board*Niagara Catholic (NCDSB)Niagara Public (DSBN)Mon AvenirPrivate SchoolHomeschoolOtherPlease Specify:* School Is your child currently on an Individual Education Plan (IEP)? (If yes, please attach a copy of the IEP with other supporting documents to this form or email upon completion)* Yes No Present Placement:* Regular Class Regular Withdrawl Support Special Class Does your child have any allergies or nutritional alerts that we should know about?* Yes No Please Specify: Does your child have any SEVERE allergies that require an Epipen?* Yes No What allergy does your child carry an EpiPen for?* Has your child participated in: Speech Therapy Visual Therapy Motor Therapy Psychotherapy Occupational Therapy Does your child have: Corrective Lenses Hearing Impairment Hearing Aid(s) Other Medical Concerns* E.g. Epilepsy, Diabetes, Nosebleeds etc.Doctor's Name Doctor's Phone NumberEmergency Contact - Name*In case primary contact cannot be reached, please provide information other than the caregivers. Emergency Contact - Phone*Emergency Contact 2 - Name Emergency Contact 2 - Phone Does your child have a formal diagnosis of a learning disability? (i.e. reading disability (dyslexia), math disability (dyscalculia), writing disability(dysgraphia))*Please visit the website for the definition of a learning disability. Yes No I don't know Type of LD: Who made the diagnosis? When? Note: To be accepted into the program your child does not have to be formally diagnosed or identified with a learning disability, but must show signs of having a suspected learning disability.Is your child diagnosed with other exceptionalities?*(i.e. AD(H)D, OCD, Autism, Auditory Processing Disorder, Intellectual Disability) Yes No Please list all exceptionalities and dates of diagnosis.* What are your child’s strengths and weaknesses in relation to their learning disability?Personal Strengths*i.e. kind, caring, friendly, funnyAcademic Strengths*i.e. addition/subtraction, organization, reading novels, art classChild's special interests, abilities, hobbies, sports?*i.e. baseball, swimming, art, video gamesSpecify what areas your child struggles with because of their learning disability, regardless of if they have an official diagnosis*i.e. adding two digit numbers, reading long words, focusing, math, social skills etc. What embarrasses your child most?(i.e. difficulties in group setting, being singled out)Does your child tire quickly when completing academic tasks?* Yes No How does your child function in a group setting?* (i.e. better one-to-one, is shy in a group etc.)What would you like the staff and volunteers working with your child to know about them?* Does your child follow verbal directions well?* Yes No Does your child follow written directions well?* Yes No Do you believe your child would be able to engage in an online learning environment (i.e., remain focused, follow instructions given)?* Yes No Please identify any behavioural issues the LDANR should be aware of:Physical Aggression*(i.e. hitting/kicking/biting) Yes No Please provide further detail:Verbal Aggression*(i.e. swearing/insulting others/disrespectful language) Yes No Please provide further detail:Defiant Behaviours*(i.e. refusals to participate/transition) Yes No Please provide further detail:Tendency to Flee*(i.e. run/escape when frustrated/upset) Yes No Please provide further detail:Other than those behaviours listed above, if your child displays other forms of behaviour issues, please list them in the space provided:**Refunds will NOT be provided if your child is removed from a program due to misconduct. Are you familiar with the Microsoft Teams platform?*The LDANR uses Microsoft Teams as our online program platform. If accepted into the program, we will use this information to identify families who may require additional support accessing the platform. Yes No Somewhat Please confirm that you would like your child to participate in this opportunity by carefully reading and agreeing to the statements of understanding below: I acknowledge that this is an online learning program and my child may require my assistance to navigate this learning experience. I confirm that my child will have access to a working device (i.e. computer, tablet) with microphone, camera, and internet connectivity. Waivers and Conditions of Enrollment: I hereby authorize the administration of any and all emergency medical attention that my child might require as a result of injury or sickness while attending LDANR programs. I hereby agree to comply with the LDANR's policy on anti-discrimination, violence and harassment. This is with the understanding that non-compliance may result in my removal from LDANR programming, thereby requiring a designate to pick-up and drop-off my child. I hereby release the LDANR, its directors, staff, agents and members from any loss, personal injury, accident, misfortune or damage to the above-named or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above-named participant. I understand that the information collected on this form will only be used to assess my child's eligibility for programming, to make the LDANR aware of any medical or allergy concerns for my child, and to ensure safe pick-up and drop-off of my child. This information will only be shared with LDANR staff and volunteers. I understand that for the program to be effective, and out of respect for the program volunteers and those who did not get a spot in the program, LDANR requests that families commit to attending each session of the program. If attendance is irregular or too many sessions have been missed the participant will be asked to leave the program to open the spot up to another participant. I understand that for the safety of the volunteer staff and other participants, LDANR has the right and responsibility to take actions such as phone calls home and possible dismissal from program if a child exhibits continual inappropriate behaviour. I understand that the LDANR charges a fee for our programs, which must be paid prior to the program start date. For more information on program fees, please visit the program-specific pages on the LDANR website. If families require financial aid to access the program, families may apply for subsidy by filling out a Program Subsidy Application Form. I understand that for a program to run, enough eligible participants have to apply for the program. If there is low enrolment, the LDANR has the right to cancel any program at any time. I understand that, if the LDANR must cancel a program date due to circumstances outside of their control (e.g., inclement weather), no refunds will be issued. The LDANR will make an effort to reschedule the cancelled session where possible, but there is no guarantee that a cancelled session will be made up. I understand that data is collected from LDANR programs to be used when reporting to funders/sponsors. All information used for reporting purposes is kept confidential and only used by LDANR staff. Participant names are removed and participant data is kept anonymous. Possible data sources used for reporting purposes include test scores, pre and post tests, ages, type of LD diagnosis. If you do not wish for your child's assessment data to be used for research purposes, please make note in the comment section below, or contact the LDANR office. I understand that any online programming will take place through a third-party, web-based learning platform. LDANR will not be held liable in the event of a privacy or security breach related to the third-party. Payment instructions:Prior to making any payments, please wait to receive notice of your child's acceptance into the program you've applied for. With the temporary closure of the LDANR's physical office due to COVID-19, only payments made via PayPal will be accepted. Cancellation policy:Cancellations must be made at least one week prior to program start in order to receive a partial refund (an administration fee may apply). Please note that membership payments cannot be refunded. APPLICATION FORMS THAT ARE INCOMPLETE OR THAT DO NOT HAVE THE RELEVANT SUPPORTING DOCUMENTS WILL NOT BE ACCEPTED.I have read and hereby accept the above waivers and conditions of enrolment and give the LDANR permission to share my child's information with the appropriate staff and program volunteers.* I agree Please type your name in the space below to confirm that you have read and agree to the waivers and conditions of enrolment:* Photo Consent*I give consent to the LDANR to take photographs and/or videos of my child while at LDANR programs for the purpose of promoting the LDANR's programs. Promotion may include advertising on the following LDANR platforms: Twitter, Facebook, website, annual report, program pamphlets, newsletter, and PowerPoint presentations. Yes No Communication Consent*I give consent to add my email address to any future mailing lists or notifications sent by LDANR and LDAO. Notifications may include emails with updates/reminders of program application dates, newsletters, and upcoming events/fundraisers. Please note, you can unsubscribe at any time and, other than this communication, LDANR/LDAO will not contact you directly nor give out mailing/email lists to anyone outside the relevant chapter to which they belong. Yes No ***Please note, by checking 'NO' LDANR will only provide you with important program information via phone call.Bingo Volunteer*As a non-profit organization, LDANR relies on Bingo funds to keep our program costs low. However, to receive these funds we must have two (2) volunteers attend each assigned Bingo session (1-2 per month). Please indicate below which Bingo sessions, if any, you would be interested/available to volunteer at: Niagara Falls Bingo (1-2 Wednesdays/year, 3:00 - 5:30 pm) St. Catharines Bingo (1-2 Sundays/year, 7:30 - 9:30 pm) Those dates/times do not work for me. How else would you support LDANR? (check all that apply) Attend fundraising events Volunteer at fundraising events Sponsoring/Donating to event Social Media Sharing Supporting DocumentsIf you have your child's supporting documents on hand, you can upload them in the space below. If not, the documents can be emailed/scanned to the program coordinator after you have submitted the application.Supporting documents include: Most recent report card or progress report, Teacher Feedback Form, Individual Education Plan (if applicable), Assessments (if applicable). Please note: Applications are not considered complete until your child's most recent report card or progress report has been received. Drop files here or Select files Max. file size: 32 MB, Max. files: 4. Teacher Feedback Form Please have your child's teacher complete the Teacher Feedback Form below. This will help LDANR further determine your child's needs for the program.Click Here for the Teacher Feedback FormQuestions or CommentsIf you do not receive a confirmation/thank you message after submitting your application please contact the office at info@Ldaniagara.org to ensure we received it. CAPTCHAEmailThis field is for validation purposes and should be left unchanged.