Applicant's Email Address Email (required) Child's Legal Name (As Stated on Birth Certificate) First Name (required) Last Name (required) Middle Name Given Name - if different from legal/AKA Additional Information Date of Birth (required) MaleFemale With whom does the child reside? (e.g., hospital, Mom, Dad, Grandparent) NextStep 2 Parent/Guardian 1 Guardian Name Address City/Town Postal Code Email Please enter at least one of the following phone numbers: Home Phone Cell Phone Work Phone Parent/Guardian 2 (if different from child) Guardian Name Address City/Town Postal Code Email Please enter at least one of the following phone numbers: Home Phone Cell Phone Work Phone BackNextStep 3 If you wish to declare that you are an Aboriginal person, please specify. (This information is for Alberta Education) —Please choose an option—Non-Status Indian/First NationsStatus Indian/First NationsMétisInuit Languages spoken in the Home Is the child a Canadian citizen? (required) —Please choose an option—NoYes If English is not your first language, would an interpreter be helpful? —Please choose an option—NoYes BackNextStep 4 Does your child have a formal diagnosis? (required) —Please choose an option—NoYes If yes, please state what the diagnosis is and what date it was given If no, please indicate areas of delay. If your child has had any of the following assessments done, please check the assessment category and add the date when each assessment was done. Alberta Education requires assessments to be dated after March 1 of the current year. Speech Occupational Therapy Physio Therapist Home Care Audiologist Psychologist Psychiatry Feeding Clinic/Home Nutrition Preschool Assessment Service Other Please add any additional information about each assessment Please list any agencies or programs your child is currently, or has been previously, involved with (e.g. IPAS, Glenrose, Elmtree, Early Intervention, CASA, FSCD, Specialized Services). Please list any specialists your child has been involved with on a regular basis (e.g. neurologist, pulmonologist, audiologist) Child's Pediatrician Pediatrician's Name Phone Number Family Doctor Doctor's Name Phone Number BackNextStep 5 Tell us about your child's development Lifting Required?YesNo Weight of child Lbs/Kgs?LbsKg Communication —Please choose an option—VerbalNon-verbalSigningPictures Speech and Language Social Interaction Behaviour Management Feeding Issues Visual/Sensory Impairments Other MobilityScootingCrawlingWalkingWheelchair Any medical procedures/needs (e.g. oxygen, g-tube fed, seizures, etc.) Social Worker Social Worker's Name Phone Number Email Childcare Provider (if applicable) e.g. daycare, day home, grandparent, etc. Childcare Provider Name Phone Number Email BackNextStep 6 Childcare Provider (if applicable) e.g. daycare, day home, grandparent, etc Who referred you to our program? Is there anything else we need to know about your child and/or family? By clicking the "submit" button you certify the submitted information is accurate and true. Back