Step 1 of 9 11% To apply to the Y2Y program: Fully complete each question on the application form and click submit (please note: you cannot save). Submit supporting documents. Supporting documentation may include any of the following documents: the applicant's Individual Education Plan, Report Card, Post-Secondary Accommodations, Psycho-Educational Assessment, Functional Limitations Form etc. Following screening, accepted applicants will be notified closer to the program start date. 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 participants. 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.Who is completing this application?* I am a caregiver applying for the program on behalf of an individual with a diagnosed or suspected learning disability. I am an individual with a diagnosed or suspected learning disability applying for the program. Has the applicant participated in LDANR programming previously?* Yes No How did you hear about the LDANR?* Flyer/Brochure Friend/Family Member LDANR Communication (email, website, etc.) Your school/teacher Y2Y Program Schedule*Please note: The Y2Y Program only runs the last Wednesday of each month. Please click the box below to indicate that the applicant is available to attend Y2Y on the last Wednesday evening of each month. I confirm the applicant is available Wednesday evenings for the Y2Y Program Please note, the LDANR's primary form of communication is through email. Primary Contact Name*The Primary Contact is the person who will receive communication about the program from LDANR staff. Mr.Mrs.MissMs.Dr.Prof.Rev.None Title First Name Last Name Primary Contact Email* Primary Contact Phone Number*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 Secondary Contact NameThe Secondary Contact is the person who will be contacted if the Primary Contact cannot be reached. Mr.Mrs.MissMs.Dr.Prof.Rev.None Title First Name Last Name Secondary Contact Email Secondary Contact Phone NumberMember Status* Non-Member Current Member Who does the applicant primarily reside with?* Who has custody of the applicant?* Applicant's Name*This is the name of the individual who would be attending the program, if accepted. First Last Applicant'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 Does the applicant have any SEVERE allergies that require an Epipen?* Yes No What allergy does the applicant carry an EpiPen for?* Other Medical Concerns* E.g. Epilepsy, Diabetes, Nosebleeds etc.Doctor's Name Doctor's Phone NumberEmergency Contact - Name*In case the Primary Contact cannot be reached. Emergency Contact - Phone*Emergency Contact 2 - Name Emergency Contact 2 - Phone Does the applicant 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 the applicant does not have to be formally diagnosed or identified with a learning disability, but must show signs of having a suspected learning disability.Is the applicant 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.* Applicant's special interests, abilities, hobbies, sports?*i.e. baseball, swimming, art, video gamesWhat embarasses the applicant most?i.e. difficulties in group setting, being singled outHow does the applicant 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 the applicant to know about them?* Does the applicant display verbally aggressive behaviour?*(i.e. swearing/insulting others/disrespectful language) Yes No Please provide further detail:Other than verbal aggression, if the applicant displays other forms of behaviour issues, please list them in the space provided: 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 individuals who may require additional support accessing the platform. Yes No Somewhat Please confirm that you would like the applicant to participate in this opportunity by carefully reading and agreeing to the statements of understanding below: I confirm that the applicant 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 the applicant 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/my child's removal from LDANR programming. 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 applicant. I understand that the information collected on this form will only be used to assess the applicant's eligibility for programming, to make the LDANR aware of any medical or allergy concerns for the applicant, and to ensure safe pick-up and drop-off of the applicant. 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 participants 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 participant exhibits continual inappropriate behaviour. 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 the applicant'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. 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 the applicant'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 the applicant 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 the applicant'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 documentation may include any of the following documents: the applicant's Individual Education Plan, Report Card, Post-Secondary Accommodations, Psycho-Educational Assessment, Functional Limitations Form etc. Drop files here or Select files Max. file size: 32 MB, Max. files: 4. Questions 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. CAPTCHANameThis field is for validation purposes and should be left unchanged.