Learning Program of Orange County Registration LP Orange County Program Application Name First Last OrganizationRoleParentProfessionalCaregiverAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Student/Child InformationStudent/Child's Name First Last Student/Child's Birth Date Date Format: MM slash DD slash YYYY Student/Child's GradeStudent/Child's SchoolSchool PlacementPublic School - General EdPublic School - Special Education ClassroomPublic School - Blended ProgramHome SchoolCharter SchoolPrivate SchoolOtherSchool Placement: OtherOC ProgramAfter School AcademyLearning Program OCLearning Program OnlineTeen TimeTutoringSchool DistrictFood allergiesPlease list any allergiesIndependent in restroomYesNoWhat strategies do you use to promote positive behavior and/or discourage negative behavior that will enable us to work safely and successfully with the participant?(i.e. schedules or reward systems)Does your participant have a history of physical outbursts(i.e. kicking, spitting, biting, etc.)? If so, please explain and suggest calming or self-soothing strategies that work best for them. What are favorite activities, movies, music, hobbies or other interests of the participant so that our volunteers can relate better to them?Can communicate their needsYesSometimesNoWhen upset can manage their emotionsYesSometimesNoConsistently follows simple directionsYesSometimesNoCooperates with othersYesSometimesNoComfortable with physical cuesYesSometimesNoLikes to be playfully motivatedYesSometimesNoBenefits by using pictures to convey meaningYesSometimesNoGets frustrated easilyYesSometimesNoHas trouble staying focusedYesSometimesNoGets upset by loud, sudden noisesYesSometimesNoGets upset by background noise such as music or talkingYesSometimesNoElopes when excited or upset.YesSometimesNoPayment MethodCheckCredit CardDown Syndrome Foundation of Orange County (“DSF”) gather photos and video of people with Down syndrome, their families and friends for the purposes of education, celebration, promotion and awareness. DSF and our Learning Program partners also use such media as content in presentations that teach families and educators across the nation how to work with children with Down syndrome. Please read and sign the following release if you are willing to grant us permission to use photos or videos involving you, your child or family: I hereby grant DSF, and their affiliates, representatives and employees, the right to take and use photographs or video of me and/or my minor child in connection with the above-identified purposes. Please check all that apply:I agree I am a parent or guardian. I have read the above and fully understand its contents. I hereby grant permission for photograph(s)/video clips to be used in the manner described above. I do not consent.
