Step 1 of 8 12% To apply for an LDANR program please follow these steps: Fully complete Steps 1-8 of the Program Application Form and click submit (please note: you cannot save). Submit the following supporting documents: - most recent report card OR progress report (required); - Teacher Feedback Form (if possible - Download the Teacher Feedback Form); - Individualized Education Plan (if applicable); - Assessments (if applicable); - 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. If you require financial assistance, please click here to complete and submit a program subsidy application. This information will be kept strictly confidential. It will only be shared with LDANR staff, program staff and volunteers working with children. Please remember these programs are designed for individuals with learning disabilities, not other exceptionalities. If unsure of eligibility, call the office prior to completing the form at 905-641-1021Member Status*Non-MemberCurrent MemberHas your child participated in LDANR programming previously?*YesNoProgram*Month/Year*How did you hear about LDANR?* Flyer/Brochure Friend/Family Member LDANR Communication (email, website, etc.) Your School/Teacher Other Please specify:Participant's Name* First Last Birth Date (dd/mm/yyyy)* Date Format: DD slash MM slash YYYY Age*Grade*Guardian's Name* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Please provide a phone number of where the parent and/or guardian can be reached during the program session.Home (Mother)Cell (Mother)Home (Father)Cell (Father)Home (Guardian)*Cell (Guardian)**Please note that our main correspondence is via email; please ensure our agency has the most current email address at all times.Email* Who does the child reside with?*Who has custody of the child?*Doctor's NameDoctor's Phone Number Emergency Contact Name*Emergency Contact Phone*Emergency Contact 2 NameEmergency Contact 2 PhonePerson(s) Dropping Off and Picking Up* Mom Dad Other Name of Mom:*Name of Dad:*Name of Other:*Phone Number of Other*GUARDIANS ARE RESPONSIBLE TO INFORM LDANR IF THEIR CHILD IS GOING TO BE PICKED UP BY A PERSON OTHER THAN THOSE LISTED ABOVE. Please visit resource page for the definition of a learning disability. To be accepted into the program your child does not have to be formally diagnosed with a learning disability but must show signs of having a potential learning disability.Does your child have a formal diagnosis of a learning disability? (i.e. reading disability (dyslexia), math disability (dyscalculia), APD)*YesNoI don't knowType of LD:Who made the diagnosis?When?Is your child diagnosed with other exceptionalities (i.e. AD(H)D, OCD, Autism, Intellectual Disability)? Please list all exceptionalities and dates of diagnosis.*If your child receives any special education support through school what category is your child placed in through the school? If unsure, ask your child’s teacher.Specify what areas your child struggles with because of their learning disability even if they do not have an official diagnosis (i.e. social skills, reading difficulties, math difficulties).* What are your child’s strengths and weaknesses in relation to their learning disability?Strengths*Weaknesses*Does your child tire quickly when completing academic task?*YesNoHow does your child function in a group (i.e. size of group)?*Please identify any behavioural issues LDANR should be aware of (i.e. aggression)*Does your child follow verbal directions well?*YesNoDoes your child follow written directions well?*YesNoDoes your child have any special interests, abilities, hobbies, sports?What embarrasses your child most (i.e. difficulties in group setting)?Is there any additional information you would like us to know about your child? School child is currently attending*Present Grade*Academic Level (MUST provide grade level of performance; if unsure ask child’s teacher)Reading*Spelling*Writing*Math*Is your child currently on an IEP? (If yes, please attach a copy of the IEP with other supporting documents to this form or email upon completion)*YesNoPresent Placement:*Regular ClassRegular Withdrawl SupportSpecial ClassDoes your child have any SEVERE allergies that require an Epipen?*YesNoPlease specify:*Does your child have any other allergies or nutritional alerts that we should know about?*YesNoPlease specify:*Will your child need to have medication administered during the program? Please note medication will only be administered by LDANR during day programs.*YesNoDoes your child have: Corrective Lenses Hearing Impairment Hearing Aid(s) Has your child participated in: Speech Therapy Visual Therapy Motor Therapy Psychotherapy Program SelectionVisit the program page on the website to read about the program specifics. Please select your program preference from the list below:*Reading Rocks (Grades 2 - 10)JUMP Math (Grades 1 - 8)B.E.S.T. Self-Advocacy (Grades 3-5)Let's R.E.A.D. (Grades 2-4)Reading Rocks Jr. (ELKP-Grade 1)S.L.A.M. Summer Camp (6-11 Years)If you are interested in more than one program, please select any other programs of interest from the list below: Reading Rocks (Grades 2 - 10) JUMP Math (Grades 1 - 8) B.E.S.T. Self-Advocacy (Grades 3-5) Let's R.E.A.D. (Grades 2-4) Reading Rocks Junior (ELKP - Grade 1) S.L.A.M. Summer Camp (6-11 Years Old) Please select the location in which you wish to participate. Visit the program page on our website to see what locations the program is currently offered in:* Select All St. Catharines Welland Niagara Falls Fonthill Beamsville Fort Erie Port Colborne In the event that your location of choice fills up, would you like to be considered for another location?YesNoPlease select all that apply:* St. Catharines Welland Niagara Falls Fonthill Beamsville Port Colborne Fort Erie Please select the days of the week that you are available for your child to attend program. Check all that apply. Visit the program page on our website to see what days the program is currently offered on:* Mondays & Wednesdays Tuesdays & Thursdays Wednesdays only (*BEST*) Full-day, Monday - Friday (*S.L.A.M.) Waivers and Conditions of Enrollment: I hereby authorize photographs and/or videotaping to be taken of my child while at the Learning Disabilities Association of Niagara Region (LDANR) for the purpose of promoting LDANR's programs. 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 Learning Disabilities Association of Niagara Region programs. I hereby agree to comply with the Learning Disabilities Association of Niagara Region policy on 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 Learning Disabilities Association of Niagara Region, 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 Learning Disabilities Association of Niagara Region 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. 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 program promotion may include advertising on the following LDANR platforms: Twitter, Facebook, website, annual report, program pamphlets, newsletter, and powerpoint presentations. External advertisement may include: newspaper or TV Cogeco coverage. If you do not wish to authorize a specific form of advertisement listed above, please make note in the comment section below, or contact the LDANR office. 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. Deadline for applications for all programs is two weeks prior to the start date of the program unless stated otherwise. Payment instructions:Prior to making any payments, please wait to receive notice of your child's acceptance into the program you've applied for. Payments can be made with cash, cheque (payable to Learning Disabilities Association of Niagara Region) or MasterCard/Visa (either online - see Membership page - or by calling the LDANR office). Cancellation policy:Cancellations must be made at least one week prior to program start in order to receive a refund (a $10 administration fee may apply). Cancellation for SLAM must be made two weeks prior to program starting in order to receive the refund. 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:*I give the LDANR consent to email me with important program-specific information and details.*YesNo***Please note, by checking 'NO' LDANR will only provide you with important program information via phone call.I give consent to add my email address to any future mailing lists or notifications sent by LDANR and LDAO (i.e. program application dates, newsletters, 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.*YesNo***Please note, by checking 'NO' you will not receive notifications of upcoming program application dates or upcoming events.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, Teacher Feedback Form, Individualized Education Plan (if applicable), Assessments (if applicable). Please note: Applications are not considered complete until all supporting documents have been received. Drop files here or Teacher Referral Form Please have your child's teacher complete the Teacher Referral Form below and send it to us. This will help LDANR determine your child's needs for the program.Download the Teacher Referral FormQuestions or CommentsIf you do not receive a confirmation/thank you message after submitting your application please contact the office at 905-641-1021 to see if we received it. PhoneThis field is for validation purposes and should be left unchanged.