ADMISSION FORM Select Full days or Half days Full days Half days Full day Mon Tue Wed Thu Fri Half day 3 4 5 Admission Date* DD dash MM dash YYYY Withdrawal Date* DD dash MM dash YYYY Child’s name* Gender* Male Female Date of Birth* DD dash MM dash YYYY Age*Address* Your relation with the Child?* Mother Father Guardian Other Name* Email* Home*Cell*Work*Home Address* Doctor’s name* Doctor’s Address* Doctor’s Phone*Emergency Contacts (name; relationship; phone numbers & address)*Release to (names and relationship)*Specialized adaptationsHand over hand assistance for feeding and classroom activities* I agree Stimulating inside the child’s mouth before/after meal times with a specialized spoon or probe provided by the parent* I agree Elevate bed at sleep time (when deemed necessary by staff)* I agree Use of reinforcements (dependent on what the child would work for)* I agree Use of specialized equipment (chairs; benches; stools; walkers etc)* I agree Use of switch activated equipment* I agree Community ServicesInfant & Child Development*ContactConsent to exchange informationReferral Resources FEC (For Exceptional Children)*ContactConsent to exchange informationReferral Durham Behavior Management*ContactConsent to exchange informationReferral School attending or will attend*ContactConsent to exchange informationReferral Grandview Kids*ContactConsent to exchange informationReferral CCAC*ContactConsent to exchange informationReferral Kinark*ContactConsent to exchange informationReferral Other*ContactConsent to exchange informationReferral Is there anything else that we should know about your child, your goals, expectations or the concerns that brought you to our services?* Medical HistoryChild’s Name* History of Communicable Diseases (list the ones your child has had in the past) eg. Rubella; Measles; chicken pox etc*Does your child have allergies?* Yes No (if yes please complete allergy alert form)* Yes No Does your child have a diagnosis?* Yes No Please provide details* Yes No Do you have any concerns about your child’s development in the following area? Please provide detailsHearing* Yes No Vision* Yes No Eating* Yes No Mobility* Yes No Speech* Yes No Social/emotional* Yes No Cognition* Yes No Attention span* Yes No Self Help* Yes No My child likes to eat:*My child does NOT like to eat:*Consent* By checking this box you are agreeing the terms and conditions mentioned on the form and also confirming that the information above is accurate.*CAPTCHACommentsThis field is for validation purposes and should be left unchanged.