Holland Bloorview FIRST®Robotics Program

JUNIOR PROGRAM APPLICATION FORM –FALL 2017

Please note that submitting an application does not guarantee acceptance.
Individualswill be contacted regarding the status of their application.

Please submit your application to: Andrea DeFinney, by Friday, August 25th 2017

Fax Number (416) 422-7037

Section A – Application to programs Check only the program(s) you wish to apply to:

JUNIOR PROGRAM , ages 6 – 9
Wednesday: 5:30pm – 7:30pm
October 4th, 11th, 18th, 25th, November 1st, 8th
Level 1 Level 2

Section B – General applicant information

Last name, First name: / Parent name:
Address (#, Street, Unit #):
City/Town: / Province: / Postal Code:
Email:
Gender:
Male Female / Date of birth (dd/mm/yy): / Telephone:Please provide a number we can reach you during the day time or where we can leave a message.
Home # ()
Cell # ()
Work # ()
Health Card Number / Version Code / Is your child currently a client of Holland Bloorview? No Yes
Current Grade or Program at school:
Name of School:
Has you/your child participated in one of our programs before? No Yes
If yes, please write the names of the programs and staff you worked with:
Do you give permission for our team to contact any of the above employees regarding this application?
No Yes

Section C – Description of disability/health condition

Name of disability/healthcondition (diagnosis) / Do you have any other diagnoses?
Learning disability
Hearing loss Vision loss
Other (please specify)
Can your child use a standard keyboard and mouse? If not, what equipment is needed?
No Yes
Are there any concerns with being able to pick up, build with or manipulate Lego pieces?
No Yes Comments:______
How do you/your child communicate?
Verbally
Alternate method (please specify) / Do you/your child require assistance with personal care? (e.g. toileting)
No Yes
Will you require medication during the program hours?
No Yes
Assistive devices
None Walker
Manual wheelchair / Power wheelchair Scooter
Other, please specify
Does your child require 1:1 assistance/ supervision to participate in activities?
No Yes If yes, Please explain the type and frequency of support required:
Does your child have any behavioural needs i.e potential harm to others or self, or the potential to wonder or leave a program area? No Yes
If yes, please describe: ______
Please note that 1:1 support (medical or behavioural) is not provided for these programs. In some programs we can accommodate a 1:1 worker but it in all cases it is the participant’s responsibility to schedule and pay for the worker.

Section D – Goals

Why do you/your child want to attend this robotics program?
Please list 1 or 2 specific goals related to the program.(examples: skills you would like to learn, experiences you want to have, social goal, participation goal, learn knowledge STEM)
Do you have past experience with FIRST Lego League:
Do you have past experience using Robotics:
Section E – Referral source - How did you hear about our programs?
Flyer in mail
Recreation, Respite &
Life Skills Fair / From friend/family
Holland Bloorview service provider
School / Holland Bloorview website
Facebook or twitter
Other, please specify

Section I: Verification and signature

I verify that the information that has been given in this application is complete and accurate to the best of my knowledge.
Applicantsignature: / Date (dd/mm/yy):

Please return this form to:

Holland Bloorview Kids Rehabilitation Hospital | Participation & Inclusion

Attention: Andrea DeFinney | 150 Kilgour Road, ON M4G 1R8 |Fax: 416.422-7037

Phone: 416-425-6220 Ext. 6216 | Fax: 416.425-9177

The personal information you give us on this form helps us provide you with services at Holland Bloorview. We collect, use and share this information under the authority of the Public Hospitals Act.If you have questions, please contact the privacy office at 416-425-6220 ext. 3467 or .

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