Returning Students

Submission of forms does not equate to acceptance in program.
The Conductive Learning Center will notify you as to acceptance into the program.
Please click here for a printable version of this form.

Applying for Session:

I (Sept.) II (Oct.) III (Nov.) IV (Dec.) V (Jan.) VI (Feb.)
VII (March) VIII (April) IX (May) Summer Camp

Last Session Attended in the Program:

I (Sept.) II (Oct.) III (Nov.) IV (Dec.) V (Jan.) VI (Feb.)
VII (March) VIII (April) IX (May) Summer Camp

	Child's Personal Information
Name:	*
Gender:	Invalid
Date of Birth:	** mm/dd/yyyy
Child Resides with:	*
Address:	*
City:	*
State:	*
Phone:	*

Medical Updates

Current Medications Any Changes in Medical Condition Since Last Attendance at Program Current Therapies/Schooling (type/frequency/where)

Present Condition

Please provide an update regarding current skills in:

Mobility: Self-care: Speech/Language:

General Questions

Please List Any Equipment or Adaptive Devices Your Child Uses: What are your current goals for your child? Please provide any other information you feel should be known by the staff: Form Completed by

Relationship to Child

To provide opportunities for preschool and school age children with motor challenges to achieve optimal physical, cognitive and social independence through the application and promotion of conductive education principles.

Conductive Learning Center