Learning Disabilities Association within Peel Region (North Peel)

All of the information is required to enroll your child. If you wish to enrol more than one child, you need to complete the form for each one.

Participant information
Name:

Age:

Date of birth:

Sex:
 Male Female

Please indicate the area or learning disability and/or diagnosis:

Describe the social behaviours exhibited by your child at home.

Describe the social behaviours exhibited by your child at school.

Allergies and/or health issues we should be aware of (if none, type 'none'):

Does the participant require any medications (if none, type 'none')?
(If yes, participants must be able to take on their own):

In which session do you want to enroll your child?

Program Dates and Times 2011/2012

Brampton
 Wednesdays – Sept. 28 – Nov. 30, 2011 from 6:00-7:00pm Wednesdays – Jan. 18 – Mar. 28, 2012 from 6:00-7:00pm Wednesdays – Apr. 11 – Jun. 13, 2012 from 6:00-7:00pm

Mississauga
 Fridays - Sept. 30 - Dec. 2, 2011 from 6:00-7:00pm (8-11) Fridays - Sept. 30 - Dec. 2, 2011 from 7:15-8:15pm (12-16) Fridays - Jan. 20 - Mar. 30, 2012 from 6:00-7:00pm (8-11) Fridays - Jan. 20 - Mar. 30, 2012 from 7:15-8:15pm (12-16) Fridays - Apr. 13 - Jun. 15, 2012 from 6:00-7:00pm (8-11)  Fridays - Apr. 13 - Jun. 15, 2012 from 7:15-8:15pm (12-16)

What are your expectations of the program:

Parent's / guardian's information
Name:

Address:

Unit:

City:

Province:

Postal Code:

Home phone:

Daytime phone:

Email:

In an emergency, please notify:
Name:

Relationship:

Telephone:

Doctor's name:

Doctor's telephone:

Payment information
Please note there are fees for the program: $150/session
Members' discount: $25 off

Are you a member of the LDA?
 Yes No

Do you wish to become a member?
If yes, please add $50 to your payment to cover the annual membership fee.
 Yes No

Confirmation and submission
I acknowledge that payment must be received prior to the start of my child's participation in the program. Program fees are non-refundable and non-transferable. Payment can be made by either cash, cheque, Visa or MasterCard, but payment cannot be made online. LDANP staff will be in contact regarding payment. Cheques can be made payable to: Learning Disabilities Association of North Peel. A $25 service charge will be levied on NSF cheques.
I accept.

I acknowledge that the participants must be picked up promptly at the end of each session. Failure to comply will result in a financial penalty of $1.00/minute late, and may result in expulsion from the program and forfeiture of fees.
I accept.

I acknowledge that the enclosed information is correct, and by submitting this form I wish to enroll my child in the program. Should any information change, I will promptly notify the Learning Disabilities Association of North Peel. I grant permission to the Learning Disabilities Association of North Peel to photograph and/or record my child’s image and/or voice on still or motion picture film and/or audio tape, and to use this material for promotion through the media of newsletters, websites, television, film, radio, print and/or display form. I understand that the audio/visual material and copyright will remain the sole property of the Learning Disabilities Association of North Peel and I waive any claim to remuneration for use of audio/visual materials used for these purposes.
I accept.

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