Early Reading & Spelling Groups 2007 Enrollment Form

Early Reading & Spelling Groups

Enrolment Form

Dear Parents,

Thank you for your interest our Early Reading & Spelling Group. This programme is a wonderful way to provide your child with a boost in their essential early literacy skills. In order to ensure maximum benefit for your child, please complete this questionnaire providing as much detail as possible.

* Denotes a required field.

Personal Details:

Child's Name:	*	Date of Birth:	*
Parent's Name/s:	*	Home Phone Number:	*
Address:	*	Work Phone Number:
Email Address:	*	Mobile Number:

School Details:

School Name:	*	School Phone Number:
School Address:	*	School Year & Teacher:

Emergency Contact Details:

Emergency Contact Person:		Work Phone Number:
Relationship:		Mobile Number:
Home Phone Number:

Health Cover Details:

Health Insurance:
You should be able to claim back a significant amount from your private health fund.

Further Child' Information:

Who suggested that your child attend the Early Reading & Spelling Group?

Do you have any particular concerns about your child's academic progress?

Does your child have any particular dietary requirements (eg, no lollies or no preservatives etc.)

Does your child have any behaviours that might hinder their progress in the group? (If Yes, please describe the behaviours and note any successful strategies that you currently use.)

Please list some of your child's interests

Please list some of your child's strengths (at school or at home).

Child' Interaction Difficulty Levels:

1) Reading and writing his/her name
No Difficulty	Some Difficulty	Lots of Difficulty
2) Writing the alphabet
No Difficulty	Some Difficulty	Lots of Difficulty
3) Learning sight words for reading
No Difficulty	Some Difficulty	Lots of Difficulty
4) Learning new spelling words
No Difficulty	Some Difficulty	Lots of Difficulty
5) Retaining spelling words for a few weeks after learning them
No Difficulty	Some Difficulty	Lots of Difficulty
6) Recognising words that ryhme (sound the same at the end)
No Difficulty	Some Difficulty	Lots of Difficulty
7) Making up ryhming words (e.g. what ryhmes with mat - pat- ???)
No Difficulty	Some Difficulty	Lots of Difficulty
8) Reading vowel sounds (i-e-a-u-o)
No Difficulty	Some Difficulty	Lots of Difficulty
9) Writing vowel sounds (i-e-a-u-o)
No Difficulty	Some Difficulty	Lots of Difficulty
10) Understanding what he/she reads
No Difficulty	Some Difficulty	Lots of Difficulty
11) Learning & rembering how to spell new sounds
No Difficulty	Some Difficulty	Lots of Difficulty

Further Information:

Please describe your child's book skills (eg, can your child sit with you and look at a book, do they understand stories that you read to them, can they identify any simple words?)

If you have any other information about your child, comments about what you wish for your child to achieve from the group, or suggestions, please write them here:

How did you find out about the groups?

Thankyou for taking the time to fill in this questionnaire, it will most certainly help with ensuring that you child gains as much as possible from the group.

To assist us with future advertising please check the boxes that apply:

	School Newsletter (school)
	School Teacher (school)
	School Principal (school)
	School Counsellor (school)
	Saw flyer displayed (where)
	Friend (who)
	Other (details please)

Further Information required:

•

Due to the extensive preparation that is involved with the group, a deposit of $100 is required to secure a place for your child. The deposit should be paid ASAP as a place cannot be held without it.

Please pay via cash, cheque (made out to: Lauren Reinhardt) or Credit Card.
The deposit will count towards the total fee of $390, therefore only $290 need be paid at the commencement of the group.

•

If you have recent reports from your child's school, therapists, paediatrician etc., it is recommended that you send a copy of these with the questionnaire. The reports prove useful in preparing for your child's needs.

Note: You will be contacted shortly to complete the deposit payment and to arrange the submission of reports, upon sending this enrollment form.

Please select the group that you are interested in:

Thank you for taking the time to fill out the enrollment form and we will contact you shortly.