Dufferin-Peel Catholic District School Board
INFORMATION REGARDING THE SPECIAL NEEDS OF STUDENTS
BEGINNING JK, SK or FULL DAY KINDERGARTEN
Student's Name:
M
Surname
F Date of Birth:
Y/M/D
First
Parent(s)/Guardian(s):
Address
Home Phone
Business Phone
Dufferin-Peel School in your area (or intersection, if unknown):
Child's Special Needs: (specify diagnosis, if applicable)
physical
speech
cognitive
vision
autism
behaviour
hearing
language
Previous Assessment:
vision
hearing
other
intellectual
speech-language
other
yes
no
Medical/Health Needs:
on medication
if yes, type:
Does this medication need to be administered during school hours:
yes
no
Comments:
Self Care:
Will your child require assistance with:
1. toiletting
no
yes
If yes, specify:
verbal prompt
physical prompt
very dependent
2. dressing
no
yes
If yes, specify:
verbal prompt
physical prompt
very dependent
3. feeding
no
yes
If yes, specify:
verbal prompt
physical prompt
very dependent
Comments:
Special Equipment/Devices: eg: wheelchair, walker, augmentative communication system such as
PECs / sign language
Revised November 2011
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Agency Involvement: eg: Erinoak/Trillium Health Centre/Peel Preschool Speech & Language Services,
Autism Intervention Services (Preschool Autism Services)/others
Agency
Contact Name
Phone
Agency
Contact Name
Phone
Agency
Contact Name
Phone
Additional Comments:
Current Tax Support:
Public Schools
Separate School
Catholic Baptismal Certificate:
yes
No
I give consent to the Dufferin-Peel Catholic District School Board staff to observe my child (children)
at the current placement, to receive any current nursery school reports and to complete
an Intake Observation Form.
Date
Parent/Guardian Signature
I would appreciate a Case Conference meeting to discuss my child's entry into the
Dufferin-Peel Catholic District School Board.
My child is currently attending:
Pre-School Program:
Days in attendance and hours:
Contact Person:
Telephone Number:
PLEASE MAIL OR FAX THIS INFORMATION FORM TO:
Dufferin-Peel Catholic District School Board
Special Education and Support Services Department
40 Matheson Blvd. West
Mississauga, Ontario, L5R 1C5
Fax: (905) 890-6076
FOR BOARD OFFICE USE ONLY:
Copy forwarded to:
Special Education and Support Services Department
Family Special Education Consultant
Municipal Freedom of Information and Protection of Privacy Act: Personal information is collected under the legal
authority of the Education Act, R.S.O. 1990, and c.E.2, as amended. This information will be used to assist in developing
an educational program to meet the student's needs. Questions regarding the collection of this personal information
should be directed to the school Principal.
Revised November 2011
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