Student Intake Form

First Name (Student)

Last Name (Student)

Street Address (Student)

City/Town/Village (Student)

Province (Student)

Postal Code (Student)

Date of Birth (Student)

Gender

Number of Siblings (Student)

Birth Order (Student)

Know Allergies (Student)

First Name (Mother)

Last Name (Mother)

Street Address (Mother)

City/Town/Village (Mother)

Province (Mother)

Postal Code (Mother)

Cell Phone Number (Mother)

Home Phone Number (Mother)

Work Phone Number (Mother)

Email Address (Mother)*

First Name (Father)

Last Name (Father)

Street Address (Father)

City/Town/Village (Father)

Province (Father)

Postal Code (Father)

Cell Phone Number (Father)

Home Phone Number (Father)

Work Phone Number (Father)

Email Address (Father)*

School

Grade

Teacher Name

Is your child currently enrolled in resource?

Yes

No

Is your child currently enrolled in speech therapy?

Yes

No

Is you child enrolled in any other programs?

Yes

No

If you answered yes to the above please list and describe the other programs below.

Has your child ever been tested for a learning difficulties?

Yes

No

If yes, when were they tested?

If yes, where were they tested?

Examiner Name

Medical Information

Does you child wear glasses?

Is your child on any medications?

Does your child have a physical disability?

Is your child right handed?

Is your child left handed?

Does your child have any hearing problems?

Does your child have any allergies?

Other

Does your family have a history of learning difficulties?

Yes

No

Please share your concerns regarding you child.

What is your child good at?

What do they like to do/interests?

How did you hear about Novaread?

Type the characters*

Student Intake Form

Student

Mother

Father

Additional School Information