TRINITY SCHOOL - Linden Grove School



Application for Admission

Mid-Year Enrollment Fall Enrollment _[pic]

year

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Specialized Learning for the Whole Child

4122 Myrtle Avenue

Cincinnati, OH 45236

Phone: 513-984-2215

Fax: 513-984-2272



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Full Name of Applicant

I understand that this admissions application for my Son Daughter

is subject to the conditions stated in printed materials and the regulations of the school.

[pic] [pic] Date Signature of Parent or Guardian

Please include the following items with the completed application for admission:

$250 application fee

Copy of current IEP with parent and district signatures

Copy of current ETR with parent and district signatures

Copy of most recent Progress Notes

Picture of your child (you will not get this back)

For office use only

Date Completed Application Received:________________________________________________

Enclosed:

$250 application fee

Copy of current IEP with parent and district signatures

Copy of current ETR with parent and district signatures

Copy of most recent Progress Notes

Picture of your child (you will not get this back)

|STUDENT INFORMATION |

|First Name |Last Name |Middle Name |

|[pic] |[pic] |[pic] |

|Student prefers to be called: |Age |Current Grade |

|[pic] |[pic] |[pic] |

|Date of Birth |Place of Birth |Home Phone Number |

|[pic]/ [pic] / [pic] |[pic] |[pic] |

|Street Address |City |State |Zip Code |

|[pic] |[pic] |[pic] |[pic] |

|HOUSEHOLD INFORMATION | |

|Living Parents (check as applicable) |Marital Status |

|Father Mother Stepfather Stepmother |Married Single Divorced Widowed Separated |

|If Parents are divorced or separated, with whom does the child reside? Mother Father |

|FATHER’S INFORMATION |

|Name |Date of Birth |Occupation |

|[pic] |[pic]/ [pic] / [pic] |[pic] |

|Street Address (If different ) |City |State |Zip Code |

|[pic] |[pic] |[pic] |[pic] |

|Home Phone |Cell Phone |Email Address |

|[pic] |[pic] |[pic] |

|MOTHER’S INFORMATION |

|Name |Date of Birth |Occupation |

|[pic] |[pic]/ [pic] / [pic] |[pic] |

|Street Address (If different ) |City |State |Zip Code |

|[pic] |[pic] |[pic] |[pic] |

|Home Phone |Cell Phone |Email Address |

|[pic] |[pic] |[pic] |

|Please list any other family members or individuals who reside in your home |

|Name |Age |School |Grade |

|[pic] |[pic] |[pic] |[pic] |

|[pic] |[pic] |[pic] |[pic] |

|[pic] |[pic] |[pic] |[pic] |

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|SCHOOL INFORMATION |

|Current Grade |School |

|[pic] |[pic] |

|Address |City |State |Zip Code |

|[pic] |[pic] |[pic] |[pic] |

|Telephone Number |Principal |Public School District |

|[pic] |[pic] |[pic] |

|Has the child repeated any grades? Yes No | |

| |If yes, please list the grade(s) repeated: [pic] |

|Please list below all grades and schools the child has attended |

|Grade |School Attended |

|Nursery School / Daycare |[pic] |

|Kindergarten |[pic] |

|First Grade |[pic] |

|Second Grade |[pic] |

|Third Grade |[pic] |

|Fourth Grade |[pic] |

|Fifth Grade |[pic] |

|Sixth Grade |[pic] |

|Seventh Grade |[pic] |

|Does your child receive supportive help in school now or in the past? Yes No |

|If yes, please check the grades that special help was received for the following areas: |

|What (if any) is/are your child’s diagnoses? |Official Diagnosis|Suspected |Family History |Receiving |

| | | | |Treatment |

|Autism Spectrum Disorder | | | | |

|PDD-NOS | | | | |

|Sensory Processing Disorder | | | | |

|Auditory Processing Disorder | | | | |

|Learning Disability | | | | |

|Cognitive Disability | | | | |

|Generalized Anxiety | | | | |

|Social Anxiety | | | | |

|Obsessive Compulsive Disorder | | | | |

|Oppositional Defiance Disorder | | | | |

|Bi-Polar | | | | |

|Depression | | | | |

|Other- [pic] | | | | |

|Other- [pic] | | | | |

Does your child receive any additional services outside of school?

Provider Focus

Mental Health [pic] [pic]

Behavioral [pic] [pic] Speech and Language [pic] [pic]

Occupational Therapy [pic] [pic] Physical Therapy [pic] [pic]

Other [pic] [pic]

List current medication(s) taken regularly:

Medication: [pic] Dosage [pic] Reason: [pic]

Medication: [pic] Dosage [pic] Reason: [pic]

Medication: [pic] Dosage [pic] Reason: [pic]

Medication: [pic] Dosage [pic] Reason: [pic]

Medication: [pic] Dosage [pic] Reason: [pic]

Medication: [pic] Dosage [pic] Reason: [pic]

Medication: [pic] Dosage [pic] Reason: [pic]

Have any other medications, treatments or therapies been recommended for your child? Yes No

If yes, please describe the current status on the recommendations or decision to decline follow through:

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Does this child have allergies (food or environmental)? Yes No

If yes, please list allergies [pic] [pic] [pic]

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Is he/she being treated for the allergies? Yes No

Does he/she have frequent colds? Yes No’

Does he/she have frequent ear infections? Yes No

Does he/she have any other frequent illnesses? Yes No

If yes, please explain:

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|SPEECH, LANGUAGE AND HEARING HISTORY |

At what age did he/she speak the first meaningful word? [pic]

At what age did he/she begin to use two words together? [pic]

Currently, he/she uses speech: frequently occasionally never

The child prefers to use: speech gestures

If gestures, please give examples:

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Which does your child prefer to use? Complete sentences Phrases 1 or 2 words Sounds

Can your child be understood by parents/family? Yes No By Friends/Playmates? Yes No By Strangers? Yes No

Are there any known hearing needs or suspicions of hearing needs? Yes No

Does the child have trouble swallowing? Yes No Using a straw? Yes No

Blowing? Yes No

Does your child scream or yell excessively? Yes No

If yes, please explain.

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Is there a language spoken in the home other than English? Yes No

If yes, please explain.

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Has your child ever had a speech and language evaluation or therapy? Yes No

If yes, when and where?

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|SKILLS INVENTORY |

Mark any that are true of your child:

Difficulty handling transitions, shifting from one mindset or task to another

Difficulty doing things in a logical sequence or prescribed order

Difficulty persisting on challenging or tedious tasks

Poor sense of time

Difficulty maintaining focus

Difficulty considering the likely outcomes or consequences of actions (impulsive)

Difficulty considering a range of solutions to a problem

Difficulty expressing concerns, needs or thoughts in words

Difficulty understanding what is being said

Difficulty managing emotional response to frustration so as to think rationally

Chronic irritability and/or anxiety significantly impede capacity for problem solving or heighten frustration

Difficulty seeing the “grays”/concrete, literal, black-and-white thinking

Difficulty deviating from rules, routine

Difficulty handling unpredictability, ambiguity, uncertainty, novelty

Difficulty shifting from original idea, plan or solution

Difficulty taking into account situational factors that would suggest the need to adjust a plan of action

Inflexible, inaccurate, interpretations/cognitive distortions or biases (i.e. “Everyone’s out to get me”, “You always blame me”)

Difficulty attending to or accurately interpreting social cues/poor perception of social nuances

Difficulty starting conversations, entering groups, connecting with people/lacking other basic social skills

Difficulty seeking attention in appropriate ways

Difficulty appreciating how his/her behavior is affecting other people

Difficulty empathizing with others, appreciating another’s perspective or point of view

Difficulty appreciating how s/he is coming across or being perceived by others

Sensory/motor difficulties

Has your child experienced a big change in his/her normal activity level? Yes No

Has your child experienced a big change in his/her ability to concentrate? Yes No

Has your child experienced a big drop in school grades or school work? Yes No

Describe your concerns about your child that would be important for our staff members to be aware of regarding social and/or self-concept issues.

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|Please mark the box next to the profile that best describes your child. If your child fits into more than one profile, mark the two closest. |

| SCSC | NCSC-WISC |

| | |

|Inattentive and internally distracted: focused on internal thoughts and sensory|Appear typical, “subtly awkward and odd person” |

|input |Highly aware that they have thoughts about people and people have thoughts |

|limited/unaware of the social and situational demands imposed by the people in |about them, understand that each person has his or her own unique perspective |

|context |Lack perception of the subtleties of social cues and may be less attuned to |

|Learn best in highly predictable environments and learn core rote concepts |other’s facial expressions, body stance, and gestures |

|related to their academic skills |Typically can pay attention in a classroom but may be far more rigid than their|

|Best learning in an uncluttered 1:1 environment with active sensory regulation |peers and subtly more literal |

|treatments to help their brain and body learn to focus together |Attempt to work in groups but miss subtle cues of how to relate with peers when|

|High percentage of echoed speech |the teacher is not the leader |

|Very, very literal with weak to severely weak auditory processing skills |Tend to prefer adult attention, even during recess and lunch |

|Limited to being able to follow one-to-two step commands |Extroverts appear egocentric and monopolize conversation. Introverts tend to |

|Distressed when routine is modified or their organized materials are changed |withdraw from group communication implying they’re not interested |

|without their participation in the process |As age, they are keenly aware that they are doing something wrong socially but |

|Learn best when activities are visual, concrete, and have a logical progression|can’t determine what it is |

|that they can be taught to follow | |

| CSC | NCSC-SASC |

| | |

|Highly distracted in unstructured social situations but more capable in highly |Try to blend in or subtly fade out during social situations. Tend to function |

|structured situations |“under the radar” and try to appear as “fine” but avoid many social situations |

|Demonstrate interest in interacting with others but struggle to maintain |outside of their family. |

|attention to another when a person does not relate to them about their topic of|Highly developed social radar, often highly concerned about any thoughts |

|interest |another person is having, even if they logically understand that he or she also|

|Sensory-seeking when feeling overwhelmed |routinely has small thoughts about others when around people |

|Anxiety is centered exclusively on changes in their world, including routines, |More anxiety and intuitively doubt their social abilities |

|people and environment – NOT social anxiety |Their resistance to interact makes them appear more socially limited than they |

|Lasting issues with expressive and receptive language challenges |actually are |

|May get cartoon or movie characters stuck in their heads |When social anxiety emerges, it appears to diminish their access to their |

|Perspective taking needs to be taught |social cognition |

|May be good at decoding and math calculations but lack ability to comprehend |Huge shift in their social behavior from appearing comfortable about others, to|

|inferential information |appearing highly uncomfortable and disconnected from others |

|Lack sense of urgency/awareness of the passage of time | |

|Not accidental learners—need to be explicitly taught concepts related to social| |

|learning and social skills | |

|Difficulty with generalization | |

| ESC | RSC |

| | |

|Awkwardly engaged: issues may not be apparent without verbally relating to the |Insisters and arguers- may say they are not interested in others but are class |

|person for a few minutes |clowns or seek out people to complain to about how no one understands them—they|

|Sensory-seeking or less attentive when feeling overwhelmed or placed in large |are attention seekers by getting people to attend to their inappropriate |

|group environments |actions but then acting like they didn’t want the attention |

|Can attend especially when sitting in the front of the classroom but lack |Make rude statements to adults or peers alike and often say, “I don’t care how |

|understanding of how to modulate their own behavior like talking out of turn or|I make people think and feel!” |

|talking for extended lengths of time and inability to work well in peer based |Fair social radar but not well tuned in to how people feel about them |

|groups |Tend to think in more black-and-white terms |

|Enjoy being around others but known to be off-topic, tangential or |Does not efficiently make the connection between the fact that how they behaved|

|perseverative in communication |yesterday impacts how people treat them today or tomorrow—instead they |

|May not realize the social hierarchy and try to be friends with peer groups |understand how they want to be perceived and therefore think they ARE perceived|

|that are not a natural fit for their social ability. |this way |

|May struggle with transitions, understanding what may be next on their schedule|May have good sense of humor regarding what they think is funny and believe |

|or why their schedule may need to change— anxiety tied to the imperfections of |that everyone else enjoys the same jokes or comments as them and don’t easily |

|how the world actually works compared to the way they think the world should |understand that people may not be laughing with them. Unfortunately, when |

|work |others laugh out of nervousness or discomfort, it confirms in their mind that |

| |they are really funny, perpetuating their use of humor at the wrong time, with |

| |the wrong people, in the wrong place. |

| |Often incredibly rigid in their thinking, insisting that people follow the |

| |rules they believe should be the rules- when they don’t follow their own rules,|

| |they shrug it off as their weakness |

|FAMILY HISTORY |

Is this child adopted? Yes No If yes, at what age did the adoption take place? [pic]

Please give all known information regarding biological parents and child’s experience up to the time of adoption:

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Describe this child’s relationship with parents.

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Describe this child’s relationship with other children in the family. [pic]

Describe this child’s relationships with peers.

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What types of discipline methods are most effective in dealing with this child?

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Does this child frustrate easily? Yes No

What types of things frustrate him/her?

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It will help us in our partnership to know the goals you have for your child.

Given your child’s overall needs, we know there will be some initial goals that may differ from long term goals. List the top 3 goals you have for your child for the first year at Linden Grove.

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List the goals you have for your child’s long term future.

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Linden Grove School strives to work closely with each student enrolled. To be effective, we need to be given full information about each child and assume that you have included all important information of a medical, psychological or disciplinary nature.

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Parent/Guardian Signature Date

Return this completed application, completed release of records form, copy of child’s current IEP, copy of child’s current ETR & non-refundable $250.00 testing fee to:

Attn: Kristin Tennyson, Principal of Academics

Linden Grove School

4122 Myrtle Avenue

Cincinnati, OH 45236

Linden Grove School recruits and admits students of any race, color, gender, ethnicity, national origin, religion, disability, age or ancestry to all its rights and privileges, programs and activities. In addition, the school will not discriminate on the basis of any race, color, gender, ethnicity, national origin, religion, disability, age or ancestry in the administration of its educational programs and athletic/extracurricular activities. Furthermore, the school is not intended to be an alternative to court or administrative ordered or public school initiated desegregation.

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