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School
Readiness
Registration Form

Please complete the form to apply for our School Readiness Program.

Parent / Carer Full Name:

Relationship to Child

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Phone

Email Address

Yes, I agree and understand there is a cost involved with this program (based on the level of support needs and chosen program) and I will need to sign and return a service agreement in order to secure my child's position. *

Is you child a current Cherub Client? *

Yes

No

On waiting list for services

Preferred Day

Child Details:

Child Full Name

Date of Birth

Age

**If attending pre-school/day care:

Name of pre-school/day care

Do you give us permission to contact the pre-school/day care?

Yes

No

Contact Details

Diagnosis:

What is your child's confirmed or suspected diganosis?

Do they have an NDIS plan? *

Yes

No

Is the plan: *

Self-managed?

Plan Managed?

Plan Manager Organisation

Plan Manager Contact Name:

Plan Manager Email:

N.B: We are unable to accept NDIA-managed participants at this time.

Medical:

Does your child have any allergies or asthma? *

Yes, please give details below

No

Allergies:

Do they have an allergy action plan?

Asthma:

Do they have an asthma action plan?

Language / Communication:

How does your child communicate?

Is your child... *

Verbal

Non-Verbal

Does your child point or gesture?

Does your child respond to Yes or No?

Does your child follow non-verbal prompts such as pointing or gestures?

Key words (2-3 words)

Can your child make verbal requests?

Short phrases or sentences

Uses AAC

Can your child request using AAC?

Can your child do the following without prompting?

Share

Turn-taking

Wait their turn

Follow 1-step instructions

Sit in a chair at a table for more than 5 minutes

If prompting is require or your child is unable to do any of the above, please explain further:

Behaviour:

is there anything that can cause your child to become upset/angry/irritable?ng gtha

Please describe what your child’s behaviour looks like if they become upset/angry or irritable? e.g. do they hit themselves, hit others, run away, scream.

How long does this behaviour usually last for?

What helps calm or soothe your child if they are upset?

What do you do to keep your child, yourself and others safe.

Sensory:

Does your child have any sensory difficulties? If so, please describe:

Self Care:

Is your child toilet-trained?

Can your child:

Go to the bathroom independently?

Wipe themselves?

Wash their hands?

Put on/take off their shoes and socks?

Level of Support Needs:

The program cost and organisation is based on a 1:3 adult to child ratio. Do you think your child will need a higher level of support need?

1:2 adult to child

1:1 adult to child

N.B Please note a higher ratio of support will change the cost of the program. We will contact you once we assess the information you have provided to discuss the levels of support further. The final level pf support will be reflected in your service agreement. Upon commencement of the program if the level of support needs to change we will contact you to discuss further.

Goals

What would you like to see your child achieve as a part of their participation in our program?

Thanks for submitting! We'll be in touch soon!

Phone: 0414 697 316

kathryn@cherubdisabilityservices.com.au

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School Readiness Registration Form