Application Information

New Student Application

Submission of forms does not equate to acceptance in program.

Following receipt of this application, our Program Director, Andrea Swiger, will reach out and go through your application with you to determine if your child is a potential good candidate for conductive education. If he or she is, an assessment appointment will be scheduled. If you will not be able to travel to Grand Rapids, you will be asked to submit a Video Assessment. Guidelines for video assessment can be found here.

The Conductive Learning Center will notify you as to acceptance into the program.

Please click here for a printable version of this form.

Child's Information

Please include names, ages and genders

Mother's Information

Father's Information

Health and Medical Information

Are there any disabilities / illnesses in the family?
What it is, and when it was given
If so, please note what kind, how often, how long, main symptoms, etc.

Health and Medical Information Continued

When, and what were the results?
When, and what were the results?
Please Give the Date of the Last Medical Exams Below.

Your Child

Please note how often these occurred.

Your Child Continued

How Does Your Child Express Their Wishes or Needs?

Present Physical Condition

Lying Position
Sitting Position
Standing Position

Present Physical Condition Continued

General Questions

Please ensure you have filled out all required fields (marked with *) otherwise the form will not submit.
Back
Next
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.