Conductive Learning Center - Grand Rapids, MI

Returning Student Application Form

Please note:

Submission of forms does not equate to acceptance in program.
The Conductive Learning Center will notify you as to acceptance into the program.
Please click here for a printable version of this form.
* Indicates a required field

APPLYING FOR SESSION:

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

Last Conductive Education school session attended:*

CHILD'S PERSONAL INFORMATION

Name:*	Gender:*	Date of Birth:*
Child Resides with:*
Address:*	City:*	State:*	Zip:*
Home Phone:*	Work Phone:	Cell Phone:

Contact E-mail:*

Current Medications/Botox Treatment: (name/doses/times)

Any changes in medical condition since last attendance at program:

Current therapies/schooling (type/frequency/where):

Please list the equipment and adaptive devices that your child uses (i.e. AFOs, splints, etc.):

Please provide an update regarding current skills in:

Mobility:

Self-care:

Speech/Language:

What current goals do you have for your child?

Please provide any other information you feel should be known by the staff:

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 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