S.L.A.M. Camp Application Form Step 1 of 8 12% The information collected in this application will be kept strictly confidential. It will only be shared with LDANR staff and volunteers who will be working with the children. Application Instructions: Complete Steps 1-8 of the S.L.A.M. Camp Application Form and click submit (please note: you cannot save). Submit supporting documents. Please note: 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); - Individualized Education Plan (*required, if applicable); - Assessments (if applicable); - Teacher Feedback Form (if possible - Download 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 by April 1st at the latest. Following acceptance, full camp payments will be required by May 15th. This information will also be outlined in the acceptance email. Subsidy and payment plans may be available. Please remember these programs are designed for individuals with learning disabilities, not other exceptionalities. If unsure of eligibility, contact the LDANRoffice prior to completing the form at (905) 641-1021 or info@Ldaniagara.org.Member 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*Caregiver'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 caregiver(s) can be reached during the camp day.Caregiver 1 (Home)*Caregiver 1 (Cell)*Caregiver 2 (Home)Caregiver 2 (Cell)**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*(other than those listed above)Emergency Contact - Phone*Emergency Contact 2 - NameEmergency Contact 2 - PhonePerson(s) Dropping Off and Picking Up* Caregiver 1 Caregiver 2 Other Name of Caregiver 1:*Name of Caregiver 2:*Name of Other:*Phone Number of Other***Caregivers are responsible for keeping the LDANR informed if their child is going to be picked up by a person other than those listed above. 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 resource page for the definition of a learning disability.YesNoI don't knowType 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 potential learning disability.Is your child diagnosed with other exceptionalities?*(i.e. AD(H)D, OCD, Autism, Auditory Processing Disorder, Intellectual Disability)YesNoPlease 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, regardless of if they 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 the LDANR should be aware of:Physical Aggression*(i.e. hitting/kicking/biting)YesNoPlease provide further detail:Verbal Aggression*(i.e. swearing/insulting others/disrespectful language)YesNoPlease provide further detail:Defiant Behaviours*(i.e. refusals to participate/transition)YesNoPlease provide further detail:Tendency to Flee*(i.e. run/escape when frustrated/upset)YesNoPlease 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 sent home from a program due to misconduct.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 Individualized Education Plan (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 allergies or nutritional alerts that we should know about?*YesNoPlease specify:*Does your child have any SEVERE allergies that require an Epipen?*YesNoPlease specify:*Does your child have: Corrective Lenses Hearing Impairment Hearing Aid(s) Has your child participated in: Speech Therapy Visual Therapy Motor Therapy Psychotherapy Camp SelectionVisit the program page on the website to read about the program specifics. Please select your preferred camp location from the list below:*S.L.A.M. Camp - St. Catharines LocationS.L.A.M. Camp - Welland LocationS.L.A.M. Camp - Niagara Falls LocationPlease note: Spots are filled on a first come, first serve basis and a needs-based basis.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 Please select the week(s) that you are requesting for your child to attend camp. Check all that apply.* July 13 - 17 (St. Catharines and Niagara Falls) July 20 -24 (St. Catharines and Niagara Falls) July 27 - 31 ( St. Catharines and Niagara Falls) August 10 - 14 (St. Catharines and Welland) August 17 - 21 (St. Catharines and Welland) August 24 - 28 (St. Catharines and Welland) 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. ********** Payments: **NEW** Camp payments will be due in full by May 15th, unless a payment plan has been arranged, or subsidy has been applied for. Prior to making payment, please wait to receive notice of your child's acceptance into the camp. Refunds: Cancellations or withdrawal from camp must be made prior to June 15th to receive a refund, subject to an administrative fee. Cancellations or withdrawal from camp after June 15th will not receive a refund. Membership payments will not 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 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.YesNoI 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.YesNo***Please note, by checking 'NO' LDANR will only provide you with important program information via phone call.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 your child's most recent report card/progress report is received. Drop files here or Teacher Referral Form If possible, please ask your child's teacher complete the Teacher Referral Form below and send it to us. This will further help the 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 info@Ldaniagara.org or (905) 641-1021 to ensure we received it. NameThis field is for validation purposes and should be left unchanged.