Conductive Learning Center - Grand Rapids, MI

New Student Application Form

Please note:

Submission of forms does not equate to acceptance in program.
A processing fee of $25 (which still must be sent by postal service, Fed Ex, etc.) must be received before your application will be considered.
If you are also submitting a video for assessment, your application will not be considered complete until the $100 video assessment fee (which still must be sent by postal service, Fed Ex, etc.) is received.
The Conductive Learning Center will notify you as to acceptance into the program.
Please click here for a printable version of this form.

APPLYING FOR SESSION:

I (Sept.)	II (Oct.)	III (Nov.)	IV (Dec.)	V (Jan.)
VI (Feb.)	VII (March)	VIII (April)	IX (May)

CHILD'S PERSONAL INFORMATION

Name:	Gender:	Date of Birth:
Child Resides with:
Address:	City:	State:	Zip:

PARENT/GUARDIAN INFORMATION

Mother's Name:
Address (if different than child):
Home Phone:	Work Phone:	E-mail Address:

Father's Name:
Address (if different than child):
Home Phone:	Work Phone:	E-mail Address:

Siblings:
Name:	Age:	Gender:
Name:	Age:	Gender:
Name:	Age:	Gender:

MECIDAL AND HEALTH RECORD

Mother’s age at time of birth:

Weight at Birth:

Gestation weeks:

Apgar Score:

Family history (are there any illnesses/disabilities in the family):

Child’s Diagnosis (what is it; when was it given):

Any History of Epilepsy or Seizures (what kind; how often; how long; main symptoms):

Current Medications:

Surgeries (what kind; when):

Please describe any history of Botox treatments:

Allergies (food, medications etc.):

Special Diet (G-tube, etc.):

Hearing Tested and Results (when/what results):

Vision Tested and Results (when/what results):

Please give date of last medical exam(s):

Pediatrics:	Ophthalmologist:	Neurologist:
Ear-specialist:	Orthopedics:	Dentist:

Previous treatments, therapies ( PT, OT, Speech, other services; how often):

Is there any past Participation in Conductive Education programs? (when, where):

Other Information/Comments you would like to share:

PARENT/GUARDIAN OBSERVATIONS

1) Describe your child’s daily routine

Weekdays:

Weekend:

2) What are your child’s favorite leisure activities?

Home:

Favorite toys/games:

Outside:

3) Does your child take part in family life? Does he/she do small household jobs?

4) How does your child express his/her wishes or needs?

Does the child speak words and sentences fluently?

Does he or she follow instructions?

5) How does your child move around in the house?

Outside:

6) How does your child go up and down stairs? Yes No

7) What do you think are your child’s greatest difficulties at this time?

8) Is it easy or difficult to motivate him/her? Yes No

What does motivate him/her (peers, toys, songs...)?

9) At this time what kind of school and program is he/she enrolled in?

How many times a week does he/she attend and for how many hours at a time?

What kind of activities does he/she do while there?

10) Please share any other information you would like:

PRESENT PHYSICAL CONDITION

1) Lying position

Is he/she able to?

lift head:

roll over:

crawl:

2) Sitting position
Is he/she able to?
sit on the floor:
sit in chair	Supported or unsupported?

3) Standing position
Is he/she able to?
stand up from the floor?
If so, describe:
stand	Supported or unsupported?

4) Walking
Is he/she able to take steps? Yes No
If so, describe:

5) Fine motor movement

Is he/she able to grasp and hold different things (blocks, pencil, paper, etc.)?

6) Self-reliance

Describe how he/she eats and drinks (is there any problem with chewing or swallowing; special utensils, selffeed):

Describe what stage he/she is in regarding toilet training:

7) What kind of special aides, furniture does your child use at home?

GENERAL QUESTIONS

1) Please list the goals you have for your child while he/she is in Conductive Education?

2) Do you expect to reach these goals with Conductive Education?

3) How did you hear about the Conductive Learning Center?

This application has been completed by:

Name:

Relationship:

Email:

A $25 check or money order which serves as the initial application fee, must be mailed within one week of submitting form. Make check/MO payable to: Conductive Learning Center
Please mail fee, at least one full body photograph of your child and any medical or educational reports, etc. that will be helpful to:

Andrea Benyovszky, Program Director
Conductive Learning Center
2428 Burton Street S.E.
Grand Rapids, MI 49546
Phone: (616) 575-0575
Fax: (616) 285-1935
E-mail: abenyovszky@aol.com

Further contact will be made with you regarding assessments dates. A non-refundable assessment fee of $100 is due at the time of assessment. If you will not be able to travel to Grand Rapids, submitting a video following the Video Assessment Guidelines will suffice. Thank you.