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2020-21 Virtual Afterschool Hangout Registration Form
Child's Information
Last Name
First Name
Middle Name
Birthday
Grade Completed
Choose a grade
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Gender
Male
Female
Current School
MDPS ID#
Is the participant proficient in english?
Yes
No
Does your child have a documented disability?
Yes
No
Is the participant a child of the dependency system?
Yes
No
Other language(s) spoken in the home
Spanish
Haitian-Creole
Other
None
Does Child Have a Documented Disability?
an Individualized Family Service Plan (IFSP; if under 3)
a Section 504 Plan
an Individualized Education Plan (IEP) at school system
a medical diagnosis from a doctor
a diagnosis by a state certified/licensed professional (ex., psychologist)
disclosure by the parent or guardian describing the child’s specific condition and/or need for accommodations
Ethnicity
Hispanic
Haitian
Other
Race
American Indian
Asian
Black or African American
Pacific Islander
White
Other
We want to get to know your child better so we can provide the best possible experience in our programs. Please tell us more about your child...
Speaks and is easily understood
Speaks but is difficult to understand
Uses sign language
Uses communication device
Uses gestures like pointing, pulling, blinking
Uses sound that are not like crying or grumbling
What, if any, help does your child receive at this time? (Mark all that apply)
Behavioral therapy or services
Counseling for emotional concerns
Daily medication (not including vitamins)
Occupational therapy (OT)
Physical therapy (PT)
Special education services in school
Speech/language therapy
None
What conditions does your child have that are expected to last for a year or more? (Mark all that apply)
Autism spectrum disorder
Developmental delay (only if under age 5)
Hearing impairment or deaf
Intellectual/developmental disability (over age 5)
Learning disability (school-age)
Medical condition or illness
Physical disability or impairment
Problems with aggression or temper
Problems with attention or hyperactivity (ADHD/ADD)
Problems with depression or anxiety
Speech or language condition
Visual impairment or blind
None of the above
During Phase B re-opening priority will be able to give to a student that transition to a hybrid on-site program. The virtual program will be available for up to 40 students. Preference will be given to the first-come participants, there will be a waiting list for onsite once all slots are full.
Phase B Choice
Virtual
Hybrid (starts Oct 5th)
OnSite ONLY (starts Oct 5th)
To support your child’s successful participation in this program, in what areas might s/he need extra assistance?
No specific help needed
Developmental delay (only if under age 5)
Academic, learning or reading activities
dapting activities to take into account a visual or hearing impairment
Holding a crayon/pencil, writing, using scissors or other fine motor tasks
Managing feelings and behavior
Personal services like help with feeding, toileting or changing clothes
Sports or physical activities like running or other gross motor tasks
Using assistive device(s) like a wheelchair, crutches, brace or walker
Other
Speech or language condition
Visual impairment or blind
None of the above
How did you hear about us?
Websearch
Word of mouth
FaceBook
Instagram
Do any of the conditions marked above make it harder for your child to do things that other children of the same age can do?
Yes
No
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