Class_______

SUMMER REINFORCEMENT PROGRAM APPLICATION 2015

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STUDENT NAME________________________________Age_____Birthdate_________ ADDRESS______________________________________________________________ City Zip Parent Name_______________________________Home Phone____________________ Work Phone_______________________Cell Phone____________________ Other Phone_______________________ E-Mail__________________________________________________ Grade Just Completed_________

School District______________________

Teacher’s Name________________________

School Building ______________________

PLEASE CHECK STUDENT INFORMATION BELOW _____Attending SRP for the first time _____An SRP returnee Year?_______ _____Regular Education class _____Special Resource room _____ DRA Reading Level _____STAR Assessment Level

My child has IEP Goals in the following: Please check ____Reading ____Math ____Written Expression ____Behavior/Social Skills ____Speech therapy ____Reading therapy ____OT/PT ____Other

Is your child on the Autism spectrum? YES_____ NO _____ Does your child have a seizure disorder? YES_____ NO_____ Does your child have any allergies? YES_____ NO_____Explain:

I have enclosed the following school reports: ______Speech IEP

______Academic IEP

_____Report Card/Teacher comments

SOCIAL BEHAVIORS THAT DESCRIBE YOUR CHILD: Please indicate how your child gets along with school friends, neighborhood pals, siblings and others. How does your child respond to consequences for behavior choices both at home and at school?

HELP US TO KNOW YOUR CHILD: Please share any additional information about your child. Please indicate any medical situations regarding your child and any medications that your child is taking. Note: Our staff does not administer medications. Please include a copy of your child’s report card, IEP, teacher recommendations, etc.

TUITION PAYMENT DIRECTIONS: Please complete the application and include $100.00 deposit to hold your child’s place. Balance of the tuition is due on the first day. Total Tuition is $300.00. Deadline is May 23, 2015. Make checks payable to SUMMER REINFORCEMENT PROGRAM. Send tuition and application to: Robin Menon 1519 Brighton Way Broadview Hts, OH 440-567-2454

Tuition Fee Deposit Speech Fee Total Due

$300.00 $100.00 50.00 (optional) $300.00 without speech

Are you requesting financial aid? ______No _____Yes, if so, include letter of explanation

Inquiries about the program and services: Jane Langol at 330-725-5311 Kim Love at 330-289-5995