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

Form Date

Date

Elementary SchoolUppper Girls' SchoolUpper 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

StateSelect StateAlabamaAlaskaAmerican 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

Year198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018

MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Day12345678910111213141516171819202122232425262728293031

Phone

Cell

Student resides:

HomeResidenceOther

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:

MarriedDivorcedWidowedRemarried

Father's Occupation

Firm Name

Business Address

City

StateSelect StateAlabamaAlaskaAmerican 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:

MarriedDivorcedWidowedRemarried

Mother's Occupation

Firm Name

Business Address

City

StateSelect StateAlabamaAlaskaAmerican 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

YearYear198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018

+ Add Another School

Summer Program Name

YearYear198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018

+ 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?

YesNo

Diagnosis

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

YesNo

Does your child receive any of the following support services?

Counseling:

YesNo

Name of Provider

Telephone

Speech & Language Therapy:

YesNo

Name of Provider

Telephone

Occupational Therapy:

YesNo

Name of Provider

Telephone

Physical Therapy:

YesNo

Name of Provider

Telephone

Other:

YesNo

Name of Provider

Telephone

Medical History

Has your child ever been hospitalized?

YesNo

Does your child have any medical condition?

YesNo

Does your child have seizures?

YesNo

Is your child currently taking any medication?

YesNo

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

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