2019-2020 School Application

Student's Full Name*

First Last

Which Program are you applying for?*

Main Campus (36 Atkinson Ave)
Satellite Class (EC Patricia, EC Viewmount, Yesodei, Ner Israel)
Placement Undecided

Family Information

Father's Name*

Prefix First Last

Mother's Name*

Prefix First Last

Student's Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Home Tel:*

Father's Cell Phone*

Father's Email*

Father's Place of Work*

Father's Work Address*

Mother's Cell Phone*

Mother's Email*

Mother's Place of Work*

Mother's Work Address*

Parent's Marital Status

Married
Divorced
Separated
Widowed

Siblings

Please list any siblings and their ages at time of application

Name	Age

Student Profile

Birth Date (MM/DD/YYYY)*

Present Age*

Please enter a number from 0 to 30.

Gender*

Male
Female

My child is a current Kayla's Children Centre student*

Yes
No

Name of school/program child is currently attending*

Grade

Describe support currently receiving at school*

1:1
small group settings
not applicable
Other - please describe

Please describe here

Please list individual therapies your child is currently receiving on a regular basis.

Occupational Therapy
Physiotherapy
Speech and Language
Music Therapy
Behaviour Therapy (IBI)
Other

If other, please describe here

Please upload a picture of your child*

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

Emergency Contact

Name (other than parent or guardian)*

First Last

Phone*

Relationship to Student*

Medical Information

Immunization Records*

Will be uploaded below
Will be sent in to the office by August 1st, 2019

Upload immunization records

Accepted file types: jpg, pdf, Max. file size: 64 MB.

Doctor's Name*

Doctor's Phone Number*

Doctor's Full Address*

Diagnosis (if applicable)*

Please list all diagnoses

Has your child ever had any external formal assessments?*

Examples: Developmental, Psychoedcuational, etc. (excluding KCC reports)

Yes
No

Please list assessment types and year they were conducted*

If yes, please upload here or submit to office by August 1st, 2019

Max. file size: 64 MB.

Medical Concerns

Please list any medical condition or special circumstances that our staff should be aware of to assist us in the care of your child. The following are examples: recent surgery, frequent infections and colds, headaches, stomach aches, diarrhea, constipation, vomiting, bedwetting, sensitivity to insect bites, insomnia, anxiety reactions, emotional outbursts, gastrointestinal bleeding, biting, drooling, wounds, special equipment.

Medical Concern	Suggested Treatment

Medical Concerns

Please list any medical condition or special circumstances that our staff should be aware of to assist us in the care of your child. The following are examples: recent surgery, medication, emotional outbursts, frequent infections and colds, etc.

Medical Concern	Suggested Treatment

Medications*

Please list all prescribed and over the counter medications that your child is currently taking: (if your child is taking any medications, a separate form will be emailed to you. Please note that a copy of a prescription is required for any medication that will be administered AT SCHOOL)

Ambulatory

Student is Ambulatory
Student Utilizes Stroller
Student Utilizes Walker
Student Utilizes Wheelchair

Does your child have a specific neurological condition other than seizures?

Yes
No

Please Specify*

Does your child have a seizure disorder*

Yes
No

Has your child ever had a seizure?*

Yes
No

How long does a typical seizure last?*

How frequent are the seizures?*

Please describe the typical manifestation of the seizure:*

(For example: precipitants, colour change, aura, hallucinations, tremors, loss of consciousness, generalized or localized seizure activity, loss of posture, or other physical or behavioural manifestations)

Exact seizure protocol in the event your child has a seizure?*

(Please be extremely detailed in your description and specific in what steps should be taken)

Does your child receive Lorazepam (Ativan) or any other type of emergency seizure medication or intervention (as needed)*

Yes
No

Please notate exact dosage and when it is indicated:*

Is your child on medication to control seizures?*

Yes
No

Please specify medication*

Does your child have any allergies?*

Yes
No

Does your child have any allergies or dietary restrictions?*

Yes
No

Allergies

Please list allergies and indicate sensitivities and/or anaphylactic status

List Allergy	Anaphylaxis or sensitivity?

Dietary Restrictions: Please list, if applicable

Is an Epi-Pen required?*

Yes
No

Feeding Information

Does your child have any dietary restrictions?

Yes
No

Please specify*

Diet Consistency

Regular
Puree
Soft (easy to chew foods)

Liquid Consistency

Regular/thin
Nectar
Honey
Pudding

Feeding Skills

Self
Assistance Required

Please specify*

Does your child have a G-Tube?*

Yes
No

Please indicate the purpose of student's G-Tube*

Supplemental Feeds
Full Nutrition
Medication only
Fluids only

If your child has a G-Tube you will be sent a separate form to fill out.

Please describe your child's level of independence with self care (eg. feeding and toileting)*

Behaviour Information

Please describe your child's level of independence*

Does your child have any specific Dislikes/Fears that we should be aware of?*

Does your child have preferred items or activities that can potentially be used as reinforcement?*

Please describe your child's means of communication? (verbal, gestures, nonverbal- if so, how does your child get his/her needs met?)*

Behavioral Techniques that work (ie. timer, charts)*

Other good tips to know*

Photo Release*

Photos help KCC share the success of the program with potential families and our generous supporters. At no time will children's names and/or personal information be shared along with the photos without written consent. We greatly appreciate families who consent to a photo release.

You may photograph my child for use in brochures, media and website
My child may be included in group photos only
Please contact me before using my child's photo in print material
My child is not photo released

Additional Services

Please send me more information and pricing for the following:

Before Care (8:00 AM - 9:00 AM)
After Care Respite (3:00 PM - 5:30 PM)
After Care Recreational Programs
Pull Out Therapies (to be paid privately or through insurance)
Bussing (availability TBD)

Conditions of Enrollment*

1. Payment of the registration fee must accompany this application.
2. Post-dated cheques, payable on the 1st of the month for the full amount of the tuition, are to be delivered to the school by the end of June 2019 and/or prior to a child’s placement.
3. Please make cheques payable to Kayla's Children Centre.
4. A fee of $25.00 will be levied for all payments not honoured by your bank or Credit Card Company.
5. A service fee of 2% will be charged on all credit card payments.
6. No child may begin the program if there is an outstanding tuition balance from a prior year.
7. As a result of the commitments made to staff, if a child leaves the program before the end of the academic year, tuition will not be refunded except in extraordinary circumstances.
8. You will receive a statement of funds paid for tuition in 2019 to claim as a medical expense on your tax return. For children under four years of age in the Infant Intervention Program or Preschool Program, parents may request child care receipts. You may request therapy reimbursement from health plans. Speak to our Financial Officer for more info.

I agree to the terms and conditions listed above

Payment

Non Refundable Registration Fee: $450

Registration forms are not reviewed until payment is received

I would like to pay online
I am sending a check for $450 Payable to KCC

Registration Fee

Price:

Total

$ 0.00 CAD

Credit Card

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Billing Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Billing Phone Number*

Billing Email*

Captcha

Email

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