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LEAP Parent Form

Learning Enrichment After-School Program (LEAP) Parent Application
Person Completing Form
First name
Last name
Relationship with the child
Parent's Information
Parents’ Marital Status:
Legal guardian:
Cell phone
Emergency contact:
Phone for emergency contact
Preferred email for correspondence:
Child's Medical Record
Medicare card number
Primary emergency cell phone:
Second emergency cell phone:
Third emergency cell phone:
Has your child been given a diagnosis?
School Cycle, Level and Supports (resources)
Does your child receive any special support or therapy services?
Other Document, evaluation etc..
Upload file should be in one of the following formats: JPG, GIF, PNG, PDF, DOC, DOCX
The file should not exceed 12MB
Does your child have any significant medical needs?
Medical History
(surgeries, serious injuries, illnesses, vaccinations)
Other relevant information
If possible, my preferred medical services are:
Hospital or doctor (include name and address).
I have read and accept the terms of the Parent Consent Form for Visual Images.
Ometz professionals have my permission to contact the school personnel; psychologist, occupational therapist or speech pathologist to provide us with additional information pertaining to my child`s application dossier.