Student Form STUDENT FORM Name * First Name Last Name Middle Name Nickname Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email Address Facebook Account Telephone Number (please follow format 639068926111 and 6565 434 232) Mobile Number (please follow format 639068926111 and 6565 434 232) Age Sex Date Of Birth MM DD YYYY Name of Primary Doctor HOW DID YOU FIRST LEARN ABOUT ILLC? Doctor Therapist Website Facebook Fellow parents TV / newspapers Brochures Conference Others please specify: MEDICAL INFORMATION PLEASE PUT A CHECK (✓) MARK ON THE APPROPRIATE SPACE: PRIMARY DIAGNOSIS: Autism Cerebral Palsy Feeding Disorder Hearing Impairment Intellectual Disability ADHS Global Developmental Delay Language Delay Down Syndrome Learning Disability Visual Impairment Others: ASSOCIATED PROBLEMS: Seizure Disorder Asthma Lung Problem Kidney Problem Allergies (please specify) CURRENT MEDICATIONS: PERTINENT PRECAUTIONARY MEASURES TO CONSIDER: SERVICE INFORMATION OCCUPATIONAL THERAPY Put a check mark (✓) on the service/s your child is receiving and specify how often and where these are being received: OCCUPATIONAL THERAPY Schedule: 1x / week 2x / week 3x / week 1x / month 2x / month None Others: Where PHYSICAL THERAPY 1x / week 2x / week 3x / week 1x / month 2x / month None Others: Where SPEECH THERAPY 1x / week 2x / week 3x / week 1x / month 2x / month None Others: Where SPECIAL EDUCATION TUTORIALS Schedule 1x / week 2x / week 3x / week 1x / month 2x / month None Others: Where ANNUAL GROSS FAMILY INCOME: Below P 100,000 P 100,001 – P 300,000 P 300,001 – P 500,000 P 500,001 – P 700,000 P 700,001 – P 1,000,000 P 1,000,001 – P 2,000,000 P 2,000,001 and above ADDITIONAL NOTES: Please write any other pertinent personal information that may affect services to be provided. Thank you!
