Today M-D-Y
Form completed by (Full Name)
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YOUR First and Last Name
What is the best phone number to contact you?
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Cell
Work
Home
What is the best time to contact you?
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What is your preferred email address?
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What is your preferred language?
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English
Spanish
Creole
Other
What is your home address?
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Street Address, City, State, and Zip/Postal Code
Would you be able to bring OR arrange transportation for your child daily to our 7-week summer program
Daily and punctual attendance is mandatory for children
Drop off and breakfast: 8:00PM-8:30AM
Pick up: 3:00PM-3:0PM (After care available until 4:30PM)
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Yes
No
Would you be able to attend our weekly parent strategy group meetings held at our partnering school? Attendance to parent strategy groups is mandatory
Weekly on Wednesdays, mornings (8:30-10 am) or afternoons (3-4:30 pm).
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Yes
No
Do you have a computer, phone or tablet with video capability?
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Yes
No
What is your child's name? (FULL NAME)
First and Last Name
Are you this child's legal guardian?Please note that we will need consent from the legal guardian to continue the eligibility and enrollment process
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Yes
No
What is your relationship to the child?
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Mother
Father
Grandmother
Grandfather
Other
Other
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What is your child's predominant language?
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English
Spanish
Creole
Other
Other
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What is your child's date of birth?
Today M-D-Y
What is your child's current age?
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View equation Double check
What is your child's gender?
Male
Female
Will your child be entering kindergarten in Fall 2025?
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Yes
No
How did you hear about our program?
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Does your child have behavior problems at home and/or school?
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Yes
No
Please briefly describe these problems
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Has your child ever been diagnosed with with an Attention Deficit Hyperactivity Disorder (ADHD)?
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Yes
No
Is your child potty trained?
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Yes
No
Does your child have an Individualized Education Plan (IEP) or 504 plan?
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Yes
No
Please note you will be asked to provide a copy of the IEP or 504 plan
Has your child ever been diagnosed with a Developmental Delay or Autism Spectrum Disorder (ASD)?
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Yes
No
Does your child have any intellectual disabilities?
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Yes
No
Description
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Is your child able to express their needs (going to the bathroom, feeling hungry) verbally?
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Yes
No
Does your child have any speech/language communication concerns?
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Yes
No
Description
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Will you be able to pay the $50.00 registration fee?
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Yes
No
Please let us know why, this will allow us to provide any assistance and referrals when necessary
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We would now like to ask you as series of questions about your child's behavioral and emotional strengths and weaknesses. Please note we ask all parents the same questions.
Total hyperactivity:
View equation
Total Attention Problems:
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Total Aggression:
View equation Does your child tell you at least two things about common objects?
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Yes
Sometimes
Not yet
Does your child use all of the words in a sentence (for example, "a," "the," "am," "is," and "are") to make complete sentences, such as "I am going to the park," "Is there a toy to play with?" or "Are you com- ing, too?"
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Yes
Sometimes
Not yet
Does your child use endings of words, such as "-s," "-ed," and "-ing"?
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Yes
Sometimes
Not yet
Without giving your child help by pointing or repeating directions, does he follow three directions that are unrelated to one another?
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Yes
Sometimes
Not Yet
Does your child use four- and five-word sentences?
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Yes
Sometimes
Not yet
Example
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When talking about something that already happened, does your child use words that end in "-ed," such as "walked," "jumped," or "played"?
* must provide value
Yes
Sometimes
Not yet
TOTAL ASQ 4.6
View equation Without your giving help by pointing or repeating directions, does your child follow three directions that are unrelated to one another?
* must provide value
Yes
Sometimes,
Not yet
Does your child use four- and five-word sentences?
* must provide value
Yes
Sometimes,
Not yet
Example
* must provide value
When talking about something that already happened, does your child use words that end in "-ed," such as "walked," "jumped," or "played"?
* must provide value
Yes
Sometimes,
Not yet
Example
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Does your child use comparison words, such as "heavier," "stronger," or "shorter"?
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Yes
Sometimes
Not yet
Example
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Does your child answer the following questions?:
(Mark "sometimes" if your child answers only one question.)
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Yes
Sometimes
Not yet
What is a typical response from your child to "What do you do when you are hungry?"
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What is a typical response from your child to "What do you do when you are tired?"
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Does your child repeat the sentences shown below back to you, without any mistakes?(Read the sentences one at a time. You may repeat each sentence one time.) Mark "yes" if your child repeats both sentences without mistakes or "sometimes" if your child repeats one sentence without mistakes.
* must provide value
Yes
Sometimes
Not yet
Total ASQ 4.7
View equation We may require your child's current teacher to complete a packet of questionnaires regarding their functioning at school with your permission. Do we have your permission?
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Yes
No
If no, please let us know why
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What is the name of your child's current school?
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What is the name of your child's current teacher?
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Are you able to provide us with the teacher's phone number?
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Yes
No
Teacher's phone number
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By selecting "Yes", you consent to being contacted by a member of our team to discuss your child's eligibility and next steps
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Yes
No
Caregiver signature
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Submit
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