LEAP School Worker Form

Learning Enrichment After-School Program (LEAP) Worker Application

Person Completing Form

First name

Last name

E-mail

Relationship with the child

Student Information

First name

Last name

Gender

Date of birth

/

Address

City

Province

Postal Code/Zip

Name of School

Grade:

Is the student a returning LEAP participant?

Yes

No

Primary language spoken at home

Language in school

English

French

LEAP Criteria

The student has mild to moderate social skills deficit that impedes his or her ability to interact appropriately with peers and/or authority figures.
The student has difficulty managing homework assignments independently
The student has an assessment from the last 2 years with a diagnosis of learning and/or social/emotional challenges
The student is on a waitlist to receive a psychoeducational assessment
The student has mild to moderate emotional difficulties that impact his or her academic and school life
The student is at-risk of failing academically

Person Completing Form

Brief Description of Child’s Situation:

Comments: