Application Form Age: 6-11 years old

Dear Parents,

Thank you for your interest in LRC Services.

Kindly find below the required documents for LRC registration file:

Child’s Birth Certificate if Egyptian, or passport for foreigners,
Father’s National ID (both sides),
Mother’s National ID (both sides),
LRC Services & Charges List signed in approval,
Payment of the amount 1200 LE for Egyptians and to 45 $ for non Egyptians.

Please note that the above ite ms are MANDATORY to complete your child’s registration process.

Thank you and best regards,

LRC Management

1 Step 1

Assessment Services Application Form

Age: 6-11 years old

Personal Data:

Child’s Nameyour full name

Date of Birthof appointment

Place of Birthyour full name

Ageyour full name

Nationalityyour full name

Home Address: (please indicate district, i.e. Maadi, Zamalek, Giza, Sidi Bishr, …etc)your full name

What is the primary language spoken at home?your full name

Name of schoolyour full name

Language of Instructionyour full name

Grade/Yearyour full name

Please list specific problems your child is experiencing and/or your concerns:your full name

Please list what you would like us to provide:your full name

How did you learn about the LRC?your full name

Required Documents:

Child’s birth certificateupload

Upload

Father’s national ID or Passportupload

Upload

Mother’s national ID or Passportupload

Upload

Payment Proofupload

Upload

Family Background:

Father’s Name:your full name

Ageyour full name

Mobileyour full name

Emaila valid email

Present positionyour full name

Employeryour full name

Mother’s Nameyour full name

Mobileyour full name

Ageyour full name

Emaila valid email

Present positionyour full name

Employeryour full name

Legal Guardianyour full name

Ageyour full name

Mobileyour full name

Emaila valid email

Siblings:

Nameyour full name

Ageyour full name

Name of Schoolyour full name

Gradeyour full name

Nameyour full name

Ageyour full name

Name of Schoolyour full name

Gradeyour full name

Nameyour full name

Ageyour full name

Name of Schoolyour full name

Gradeyour full name

Office use only:

Date receivedyour full name

Date Enteredyour full name

Medical History:

1. How long was the pregnancy pre-mature or full-term

Prematureyour full name

Full-termyour full name

Duration (weeks)your full name

2. What kind of Delivery?

Normal Deliveryyour full name

C-Sectionyour full name

3. Were there any problems during or straight after birth?pick one!

Yes No

If yes, please specifyyour full name

4. Did the child need an incubator needed after delivery?pick one!

Yes No

If yes, please specifyyour full name

5. Was the child breastfed as a baby?pick one!

Yes No

If yes, please specify the durationyour full name

6. Was the child hospitalized before?pick one!

Yes No

If yes, please specify the reason and the durationyour full name

7. Does the child have any current health concerns?pick one!

Yes No

If yes, please specifyyour full name

Following is a checklist of the early accomplishments of children. Please put an X next to each item under the column giving the age at which this “milestone” first occurred. If there are items the child still cannot do, please check “Not Yet Able”.

EARLY DEVELOPMENT

	0-3 months	4-6 months	7-12 months	13-18 months	19-24 months	2-3 years	3-4 years	4 -5 years	5-6 years	Not yet Able
Sat up without help
First dentition (first tooth)
Crawled
Walked alone (10-15 steps)
Walked upstairs
Rode a tricycle
Caught a big ball
Spoke first words (Mama, Dada, etc.)
Put words together (Daddy bye-bye, Mama home, etc.)
Spoke 2-3 word sentences
Spoke clearly so strangers understood
Used fingers to feed self
Used a spoon
Fully bowel trained
Fully bladder trained
Able to dress self
Able to tie shoelaces
Able to separate easily from mother
(For school, play, etc.)

Please list languages and specify which is the family’s first, second, and third language:

Motheryour full name

Fatheryour full name

Childyour full name

Siblingsyour full name

Educational History:

Schools Attendedyour full name

Dates Fromof appointment

Toof appointment

Language of Instructionyour full name

Problems with Learningyour full name

Problems with Behavioryour full name

Schools Attendedyour full name

Dates Fromof appointment

Toof appointment

Language of Instructionyour full name

Problems with Learningyour full name

Problems with Behavioryour full name

Schools Attendedyour full name

Dates Fromof appointment

Toof appointment

Language of Instructionyour full name

Problems with Learningyour full name

Problems with Behavioryour full name

* Attach or bring copies of school progress reports to the initial interview meeting

Schooling Information:

– Has your child ever received special services at school?

When?your full name

Why?your full name

– Has your child ever repeated a grade in school?

When?your full name

Why?your full name

– Has your child ever been suspended or expelled?

When?your full name

Why?your full name

– Does your child persistently refuse to go to school?

When?your full name

Why?your full name

Please state any academic concerns, if any (for example, reading, writing, math…etc)your full name

Previous Assessments:

Has your child ever had an assessment of or therapy for:

Vision

Dateof appointment

Resultyour full name