Ivymount Outreach New Participant Application

Ivymount Outreach New Participant Application

Participant Information

First Name:    

Last Name:    

Date of Birth:   

Street Address:   

Address Line 2:    

City:   

State/Province/Region:   

Postal/Zip Code:   

Gender:    

Participant lives with:       Other please specify:   

Check the programs you are interested in the participant attending:

  Fall Athletics Tuesdays AND Thursdays

  Fall Athletics Tuesdays ONLY

  Fall Athletics Thursdays ONLY

  Fall Art Tuesdays AND Thursdays

  Fall Art Tuesdays ONLY

  Fall Art Thursdays ONLY

  Girls Club Fall II Session (Nov 4th - Dec 16th)

  Camp LOL Fall II Session (Nov 4th - Dec 16th)

  Unstuck and On Target (session starting in January, requires a $50 application fee)

  Mythbusters (session starting in January)

  Game Time (session starting in January)

  Secrets of Friendship (session starting in January)

  Conversation Club/Street (session starting in January)


 

Parent/Guardian Information

Parent/Guardian 1 

Name:   

Relationship to participant:   

Primary Phone Number:   

Alternate Phone Number:   

Email:   

 

Parent/Guardian 2 

Name:   

Relationship to participant:   

Primary Phone Number:   

Alternate Phone Number:   

Email:   

Siblings or other significant family members in the home (state name, gender, age, and relationship to applicant)


 

School Information

Participant's current school:   

Is the participant in a special education program?   

What kinds of special services, if any, does the participant receive in school?  Check all that apply.

 Occupational Therapy
 Speech/Language Therapy
 Aide in classroom
 Pull-out Services
 IEP
 Other, please specify:    


 

Health/Medical Information

Is the participant currently taking any medications? If so, please list including dose and time taken.

What is the participant's current/most recent diagnosis? Who made the diagnosis?

Please list any of the participant's significant health conditions.

Please list any of the participant's allergies.

Please list any of the participant's special diet/food restrictions.

Please list any of the participant's physical limitations.

Please describe any behavioral difficulties that the participant has (e.g. hitting, biting, self-injurious behaviors, etc.). Please be specific. Withholding information may hinder our ability to handle any crises or challenging situations.


 

Other Important Information About the Participant

What special interests and strengths does the particpant have?

What are the participant's current areas of need or challenges?

What has been done so far to try to meet the needs of the participant?

Does the participant receive any additional services outside of school?

Does the participant know his/her diagnosis? How do you manage this in your family?

Please add anything else you think we should know about the participant.

Click the button below to attach a current picture of the participant. Please add the participant's name to the subject line.


 

Unstuck and On Target Applicants Only

Please complete the following items only if you are applying to the Unstuck and On Target Program, otherwise please skip to the next section.

Click the button below to attach the participant's IEP, if available Please add the participant's name to the subject line.

Click the button below attach the participant's neurological/psychological evaluation, if available. Please add the participant's name to the subject line.

Click the button below to attach any other document that you feel would be helpful to us in making our decision. Please add the participant's name to the subject line.

Click the button below to attach a family photograph for the participant's file. Please add the participant's name to the subject line.


 

Digital Signatures (Required for all applications)

Parent/Guardian 1

I hereby make an application for the participant to attend an Ivymount Outreach Program. I have filled out all of the information to the best of my knowledge.  I acknowledge that submission of this application does not guarantee acceptance into an Ivymount Outreach Program.

Please type your name:    

Date:   

 

Parent/Guardian 2

I hereby make an application for the participant to attend an Ivymount Outreach Program. I have filled out all of the information to the best of my knowledge.  I acknowledge that submission of this application does not guarantee acceptance into an Ivymount Outreach Program.

Please type your name:   

Date:   


 

Click "Submit" below to complete your application.

 

Please note that applications for Unstuck and On Target require a non-refundable, $50 application fee.  After submitting your application, please click on the "Pay Now" button to submit this fee.  

 



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