Online application - Conductive Learning Center of Greater Cincinnati

New Student Application

Submission of forms does not equate to acceptance in program. The Conductive Learning Center of Greater Cincinnati will notify you as to acceptance into the program.

Child's First Name *

Last Name

Email Address *

Phone Number

Gender

Child resides with

Date of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Parent Guardian Section

Father's Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Cell Phone

Work Phone

Email Address

Parent Guardian Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Siblings

Medical and Health Record

Mother's age at birth

Weight at birth

Gestation weeks:

Apgar score:

Family History

Child's Diagnosis

History of Epilepsy or Seizures?

Current Medications:

Surgeries

Allergies

Special Diet

Hearing & Vision Tested & Results

Date of last medical exam

Previous treatments, therapies

Any past participation in Conductive Education programs?

Other information/comments you would like to share:

Parent/Guardian observations

Describe your child's daily routine

Favorite Leisure Activities:

Does your child take part in family life?

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

How does your child move around the house?

How does your child go up and down stairs?

What do you think are your child's greatest difficulties at this time?

Is it easy or difficult to motivate him/her?

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

Any other information you would like to share?

Present Physical Condition

Lying Position

Lift HeadRoll OverCrawl

Is he/she able to:

Sitting position

Sit on floorSit on a chair (supported or unsupported?)

Is he/she able to:

Standing Position

Stand up from the floor?Standup - supported or unsupported?

Is he/she able to:

Walking

Take steps?

Is he/she able to;

Fine motor movement

Self-reliance

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

General Questions

What goals do you have for you child?

Do you expect to reach these goals with Conductive Education?

How did you hear about the Conductive Learning Center of Greater Cincinnati?

Completed by;

Name/relationship

Email Address

Phone