Scartleigh National School
Enrolment Application Form for Placement in Special Class for Children with Autism











Scartleigh National School
Enrolment Application Form for Placement in Special Class for Children with Autism


Name of Child


 

Date of Birth


 

Address


 

School Year for Enrolment


 

Contact Telephone Numbers


 

Mother's Name


 

Father's Name


 

Religion if applicable


 

Has your child been assessed for autism?           Yes/No

If so, who conducted the assessment and when?




Has your child received a diagnosis of autism?           Yes/No


Has your child any other diagnosis of a disability? Please specify.




Has your child a learning disability?           Yes/No

If so, please specify. (If unsure please contact a member of the assessment team.)

Severe/Profound       Moderate       Mild


Has your child a learning disability?           Yes/No

If so, please specify. (If unsure please contact a member of the assessment team.)

Severe/Profound       Moderate       Mild


With regard to future schooling, what is the recommendation of the assessment team?




How would you describe your child’s general behaviour?

Very challenging         Challenging         Not challenging


How would you describe your child’s ability to communicate?

Age appropriate         Delayed         Non-Verbal

Please give examples





How would you describe your child’s ability to interact with others?

Very Sociable         Sociable         Avoids interaction

Please give examples





Outline your child’s development in the following areas. Please be specific.

Toilet training



Dressing skills



Eating



Mobility




Your child’s placement in an ASD class will be reviewed at the end of each school year. In consultation with the multi-disciplinary team the school will advise you on the future schooling needs of your child. Please note that placement in the Early Intervention Class does not entitle your child to a placement in either the special class or the mainstream school.

Signature of Parent(s) ...................................................................

Signature of Special Class Teacher................................................

Signature of School Principal ........................................................