IVDU SCHOOL APPLICATION FOR ENROLLMENT

I consent that IVDU contacts my child’s current school to speak about my child.

Form Date

Date

Elementary School Uppper Girls' School Upper Boys' School IVDU Long Island

How did you hear about IVDU?

Student Information

Student Legal First Name

Student Legal Last Name

Student Preferred Name

Primary Address

Primary Address #2

City

State Select State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Date of Birth

Year 1980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019

Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Day 12345678910111213141516171819202122232425262728293031

Phone

Cell

Student resides:

Home Residence Other

Primary Guardian Information

First Name of Primary Guardian

Last Name of Primary Guardian

Guardian Relationship

Primary Guardian Phone

Primary Guardian Email

Father's Information

Deceased

Father's First Name

Father's Last Name

Father's Marital Status:

Married Divorced Widowed Remarried

Father's Occupation

Firm Name

Business Address

City

State Select State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Business Phone

Cell

Email

Mother's Information

Deceased

Mother's First Name

Mother's Last Name

Mother's Marital Status:

Married Divorced Widowed Remarried

Mother's Occupation

Firm Name

Business Address

City

State Select State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Business Phone

Cell

Email

Schools/Summer Programs Information

School Name

Year Year 1980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019

+ Add Another School

Summer Program Name

Year Year 1980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019

+ Add Another Summer Program

Does the child speak any other languages? Please list them

Siblings Information

Name

Age

School

+ Add Sibling

Why are you referring your child to this program?

What are your goals for him/her in this program?

Services

Does the student have Medicaid?

Yes No

Diagnosis

Has your child been evaluated by the NYC Department of Education?

Yes No

Does your child receive any of the following support services?

Counseling:

Yes No

Name of Provider

Telephone

Speech & Language Therapy:

Yes No

Name of Provider

Telephone

Occupational Therapy:

Yes No

Name of Provider

Telephone

Physical Therapy:

Yes No

Name of Provider

Telephone

Other:

Yes No

Name of Provider

Telephone

Medical History

Has your child ever been hospitalized?

Yes No

Does your child have any medical condition?

Yes No

Does your child have seizures?

Yes No

Is your child currently taking any medication?

Yes No

Please list any allergies your child may have:

Does your child have difficulty with any any of the following? If yes, please elaborate:

Mobility:

Vision:

Hearing:

What are your child's interests and hobbies?

What might cause your child to get angry or frustrated?

How does s/he react?

How does s/he calm down?

What rewards does your child enjoy?

Additional Information: Please include any further information about your child's background (at home and in learning situations), in terms of particular weaknesses and strengths, that you feel would be helpful to us in planning an educational program for him/her

Form:

Please fill out the following form to reflect your view of your child's behavior:

Behaviour	Never	Sometimes	Often	N/A
Inattentive, easily distracted
Defiant
Forgets things s/he has already learned
Disturbs other children
Actively disobeys or refuses to comply with adults' requests
Is always "on the go" or acts as if driven by a motor
Has difficulty playing or engaging in leisure activities quietly
Cannot remain still
Spiteful or vindictive
Leaves seat when remaining seated is expected
Fidgets with hands or feet or squirms in seat
Not reading up to par
Argues with adults
Only pays attention to things s/he is really interested in
Has difficulty waiting his/her turn
Lacks interest in schoolwork
Distractibility or attention span a problem
Temper outbursts; explosive, unpredictable behavior
Runs about or climbs excessively where inappropriate
Poor in arithmetic
Interrupts or intrudes on others (e.g. Interrupts others' conversation or games)
Poor in spelling
Fails to finish things s/he starts
Doesn't follow through on instructions and fails to finish tasks (not due to oppositional behavior or failure to understand directions)
Excitable, impulsive
Non-compliance with medication
Self-harm behavior
Inconsistent school attendance

Please upload:

1. 1. Current photo of student
2. 2. Any current IEP's or Evaluations
3. 3. Copy of your child's insurance card

Upload File

Signature:

All information which I have supplied is current to the best of my knowledge. If I am not the parent/guardian, I am completing this form with their knowledge and permission.

Signature of person completing application

Date

Email