ŠĻą”±į>ž’ \^ž’’’[’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’ģ„Į ųæĻ=bjbjąą %Z‚j‚jµ9’’’’’’lžžžžžžžŒŒŒ8Ä Š\Ķ%ņ8N"ppppppL%N%N%N%N%N%N%$æ& ß(“r%žpppppr%ųžžpp‡%ųųųpFžpžpL%ųpL%ųTųL%žžL%p, °Ļż®ÕµČzŒ¶FL%L%%0Ķ%L%“)üü“)L%ųžžžžŁMercy Special Learning Center 830 South Woodward Street Allentown, PA 18103-3440 Phone: (610) 797-8242 FAX: (610) 797-9092 Email:  HYPERLINK "mailto:mercylearn@rcn.com" mercylearn@rcn.com APPLICATION Name of Child __________________________________ Social Security # ___________________________ Address ________________________________________ City ______________ State ____ Zip __________ Home Phone _______________________________ Mother Cell Phone ____________________ Work # _________________________ Father Cell Phone _____________________ Work # _________________________ 1st Emergency Contact Name __________________ Home Phone _____________ Cell Phone ____________ 2nd Emergency Contact Name __________________ Home Phone _____________ Cell Phone ____________ 3rd Emergency Contact Name __________________ Home Phone _____________ Cell Phone ____________ Date of Birth ________________________________ Place of Birth ______________________________ School District of Residence ________________________ Municipality of Residence ________________________ County of Residence ________________________ Parish (If Catholic) ______________________________ City / State __________________________ Baptism Date ___________ Church ________________________ City ____________ Holy Eucharist Date ___________ Church ________________________ City ____________ Confirmation Date ___________ Church ________________________ City ____________ FAMILY HISTORY Name of Father ___________________________ Date of Birth ____________________ Place of Birth ___________________________ Religion ____________________ Occupation ___________________________ Name of Mother ___________________________ Date of Birth ____________________ Place of Birth ___________________________ Religion ____________________ Occupation ___________________________ Mother’s Maiden Name ____________ Other Family Members (give name, date of birth) of brothers, sisters & others living in the home: ___________________________ _________ ___________________________ _________ ___________________________ _________ ___________________________ _________ ___________________________ _________ ___________________________ _________ ___________________________ _________ ___________________________ _________ Child lives with ___ Both Parents ___ Mother ___ Father ___ Other, name ________________________ Does any other member of family have a handicap? ___ YES ___ NO Type of handicap? ____________________________________________ Relationship to this child ______________________________________ MEDICAL HISTORY Name of your child’s present physician ______________________________ Phone __________________ Describe any physical or health problems ______________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have there been any accidents or long illnesses? ________________________________________________ __________________________________________________________________________________________ Have there been any fevers? __________________________________________________________________ Does your child have seizures? ____________________________________________________________ Does your child display temper tantrums? ______ How frequently and under what conditions? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Has your child been known to harm him/her self ? ________ Others? _____________________________ Does your child have any special medical needs? ___ YES ___ NO If yes, please explain ________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does your child have any food allergies? ___ YES ___ NO If yes, please list ________________________________________________________________________ __________________________________________________________________________________________ Is your child on a special diet or does your child have any special dietary restrictions? ___ YES ___ NO If yes, please list ________________________________________________________________________ __________________________________________________________________________________________ ASSESSMENT OF FUNCTION OF CHILD 1. Does your child have problems moving: (circle all that apply) Head Arms Hands Legs Feet 2. Check all of the following that your child can do ___ sit ___ run ___ roll over ___ swim ___ crawl ___ drink from cup ___ pull self to stand ___ build blocks ___ walk ___ watch T.V. ___ go up stairs ___ use a pencil ___ throw ball ___ draw ___ jump ___ write ___ balance on one foot COMMUNICATION 1. Does your child respond to (circle all that apply) Touch Noise Voices Speech 2. In what ways does your child respond? (circle all that apply) Moves body Moves head Gestures Makes sounds Uses speech Signs 3. The child’s speech is best described as follows (check all that apply) ___ has no speech ___ speech is not understandable at all ___ speech usually understood by family, but rarely by strangers ___ speech understood by strangers, if they pay attention ___ speech understandable but different from speech of children of same chronological age ___ speech is normal for a child of this chronological age ___ imitates some speech sounds ___ speech sometimes understood by family 4. The number of works your child uses is: ___ less than 10 ___ more than 10 but less than 100 ___ more than 100 5. Your child puts words together as follows: ___ puts 2 to 3 words together ___ speaks in sentences 6. Would you like your child to communicate differently? (circle one) YES NO 7. Does anyone try to get your child to communicate better? (circle one) YES NO Who? ______________________________________________ VISION 1. Does your child have an eye that turns up, down, in or out? YES NO 2. Can your child’s eyes follow a moving object held about 10 – 12 inches in front? YES NO 3. Is your child alert to distant moving objects? YES NO 4. Does your child blink or run his/her yes a lot? YES NO 5. Does the child turn or tilt head to look at some things? YES NO 6. Does your child seem sensitive to light? YES NO 7. Will your child accurately reach for objects held in front? YES NO 8. Do your child’s eyes seem to have a tremor or trembling in them? YES NO 9. Do both eyes follow an object brought to within a few inches of your child’s nose? YES NO 10. Does your child wear corrective lenses? YES NO INDEPENDENT FUNCTIONING 1. Check all of the following functions your child can perform: ___ feed self ___ drink from cup ___ feed self a cracker ___ button clothes ___ use spoon ___ unbutton ___ use knife & fork ___ tie laces ___ use toilet ___ put on clothes ___ set table ___ wash hands ___ make bed ___ clean teeth ___ cook ___ take bath/shower ___ make sandwich ___ help with simple household tasks 2. What is the most independent thing your child can do? ____________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 3. Does your child need any special equipment to be as independent as possible? ____________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 4. What time does your child get up in the morning? __________________________________________ 5. What time does your child go to bed at night? __________________________________________ 6. How many hours does your child watch T.V. each day during the week? ________________________ One the weekend ? __________________________________________ 7. What kind of special care does your child need? ____________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 8. How many hours a night does your child sleep? __________________________________________ FAMILY FUNCTIONING AROUND CHILD 1. Was your child diagnosed with a disability at birth? YES NO 2. What diagnosis(s), if any have your been given for your child? ____________________________________________________________________________________ ____________________________________________________________________________________ 3. Have your been given any reason(s) for your child’s diagnosis? ____________________________________________________________________________________ ___________________________________________________________________________________ 4. Briefly describe your understanding of your child’s diagnosis? ____________________________________________________________________________________ ____________________________________________________________________________________ 5. Have you accepted your child’s diagnosis? ____________________________________________________________________________________ ____________________________________________________________________________________ 6. Does the presence of your child upset any family members? YES NO Explain: ________________________________________________________________________ ____________________________________________________________________________________ 7. Has the house and/or household been changed to accommodate your child’s diagnosis? YES NO In what ways? ________________________________________________________________________ ____________________________________________________________________________________ 8. Do any family situations affect your child? (example: mealtime, family gatherings, holidays, new sibling, etc.) ________________________________________________________________________ 9. In what kind of outside activities can your child join other family members? ______________________ ____________________________________________________________________________________ USE OF COMMUNITY RESOURCES Have you sought help/services related to your child’s diagnosis? YES NO From the list below, what kind of help/services have you received? Health Care Providers: Specialists, Doctors, Clinics, Hospitals, Health Departments, Public Health Nurses, Therapists, School Nurse, Special Programs, etc……. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Early Intervention Program: Easter Seals, United Cerebral Palsy, Home Based Services, etc ….. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Social Services: Family Service, Hospitals, Counseling, Children & Youth, Family Guidance, Office of Mental Retardation, Mental Health Services, etc. ….. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Educational Services: Name of school / program is which your child is presently placed: ____________________________________ Address __________________________________________ City/State/Zip ______________________ Phone _________________________________ Type of Class _____________________________________ FUTURE FUNCTION Check all of the following activities you think your child will be able to do when he/she becomes an adult: 1. Home Activities ___ daily household tasks ___ marry ___ have a child ___ child care ___ handle money ___ buy groceries ___ household maintenance & repairs ___ child care ___ supervision of paid outside help 2. Work Activities ___ travel to work ___ relate to co-workers ___ perform tasks independently ___ drive a car ___ take direction at work ___ perform tasks with assistance 3. Social Activities ___ go to movies ___ writing ___ go to sport events ___ reading ___ listen to radio ___ go to dances ___ watch T.V. ___ hobbies ___ outdoor activities ___ dating ___ go shopping ___ arts & crafts ___ social gatherings w/friends ___ member of clubs & organizations 4. Are family members worried about your child’s future? YES NO If yes, what are they particularly concerned about: ___ education ___ social skills ___ Job training ___ transportation ___ employment ___ exploitation by others ___ living arrangements Other ___________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 5. Do family members agree on how your child should be raised? YES NO 6. 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