JAMES ANDERSON LEARNING CENTRE ADMISSIONS INTERVIEW Survey

JAMES ANDERSON LEARNING CENTRE ADMISSIONS INTERVIEW

Please answer all relevant questions completely in order to fast track the New Student Admissions Interview Process.

1. CONTACT INFORMATION

CONTACT INFORMATION Student Legal (Usual) Name
Parent/Guardian Name
Parent/Guardian Home Phone #
Cell or Work Phone #
City/Town:
Previous School (Last school attended):

2. STUDENT DEMOGRAPHICS

	Last Grade Completed	Age	Sex
Demographics	STUDENT DEMOGRAPHICS Demographics Last Grade Completed	Age	Sex

Date of Birth (MM/DD/YYYY)

3. PLEASE INDICATE WHO REFERRED YOU TO JAMES ANDERSON LEARNING CENTRE

	School Name	Administrator	Counsellor	Other School Personnel:	Other:
Select	PLEASE INDICATE WHO REFERRED YOU TO JAMES ANDERSON LEARNING CENTRE Select School Name	Administrator	Counsellor	Other School Personnel:	Other:

Additional Information on Referral (please specify)

4. REASON FOR REFERRAL:

REASON FOR REFERRAL: Chronic Absenteeism

Chronic Health/Illness

Academic Underachievement

School & Community Disengagement

Mental Health Support

Gifted Support

Attending Specialized Out of School Program (e.g. Sport Training, Acting/Actor/Performer, etc...)

Other Reason/s for Referral:

5. KEY ACADEMIC DATES:

	MM		DD		YYYY
Last day attending previous school	KEY ACADEMIC DATES: Last day attending previous school Month	/	Day	/	Year
Date of last Report Card Issued	Date of last Report Card Issued Month	/	Day	/	Year
Date of last IEP Update	Date of last IEP Update Month	/	Day	/	Year
Date of last PsychEd Assessment	Date of last PsychEd Assessment Month	/	Day	/	Year

6. KEY BACKGROUND INFORMATION

	Yes	No - Not an issue or doesn't apply.
New to catchment area (Limited Information)	KEY BACKGROUND INFORMATION New to catchment area (Limited Information) Yes	No - Not an issue or doesn't apply.
History of changing schools within the District	History of changing schools within the District Yes	No - Not an issue or doesn't apply.
Attendance difficulties (Truancy/Absenteeism)	Attendance difficulties (Truancy/Absenteeism) Yes	No - Not an issue or doesn't apply.
Academic difficulties (Failed Coursework/Grade)	Academic difficulties (Failed Coursework/Grade) Yes	No - Not an issue or doesn't apply.
Student receiving in school counselling support	Student receiving in school counselling support Yes	No - Not an issue or doesn't apply.
Student receiving out of school counselling support	Student receiving out of school counselling support Yes	No - Not an issue or doesn't apply.
Recent thoughts or ideations around Suicide (or SD35 8 Step Process)	Recent thoughts or ideations around Suicide (or SD35 8 Step Process) Yes	No - Not an issue or doesn't apply.
Recent Threat Assessment (Violent or Threatening Behaviour)	Recent Threat Assessment (Violent or Threatening Behaviour) Yes	No - Not an issue or doesn't apply.
Community/Criminal difficulties (Vandalism/Gang/Criminal Sub-cultures/Probation)	Community/Criminal difficulties (Vandalism/Gang/Criminal Sub-cultures/Probation) Yes	No - Not an issue or doesn't apply.
Limited family support/involvement	Limited family support/involvement Yes	No - Not an issue or doesn't apply.
Student ward of Ministry of Children and Family Development	Student ward of Ministry of Children and Family Development Yes	No - Not an issue or doesn't apply.
Student is supporting themselves finanically/independent living	Student is supporting themselves finanically/independent living Yes	No - Not an issue or doesn't apply.

Behavioural Issues & Additional explanations:

7. SPECIAL NEEDS CATEGORY/DESIGNATION (Must be confirmed with recent PsychEd Assessment):

SPECIAL NEEDS CATEGORY/DESIGNATION (Must be confirmed with recent PsychEd Assessment):

8. MEDICAL ALERTS OR KEY MEDICAL INFORMATION:

MEDICAL ALERTS OR KEY MEDICAL INFORMATION:

9. PARENT NOTIFICATION AND LEGAL CONFIRMATIONS:

	Yes	No
Parent has been notified of schools mandate to support non-behaviourial students who have disengaged traditional education services.	PARENT NOTIFICATION AND LEGAL CONFIRMATIONS: Parent has been notified of schools mandate to support non-behaviourial students who have disengaged traditional education services. Yes	No
Parent has reviewed schools website or received program information.	Parent has reviewed schools website or received program information. Yes	No
Parent has given permission for the sharing of information between their previous school and JALC.	Parent has given permission for the sharing of information between their previous school and JALC. Yes	No

10. ADDITIONAL ACADEMIC CONCERNS/LEARNING ISSUES, OTHER IMPORTANT INFORMATION:

ADDITIONAL ACADEMIC CONCERNS/LEARNING ISSUES, OTHER IMPORTANT INFORMATION:

1. JALC NEW STUDENT ADMISSIONS FORM