Student Testing Application Student Testing Application for Learning Disabilities Step 1 of 10 - General Information 0% General InformationName of Student:* First Last Nickname/Name Preferred:Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age:*Please enter a number from 1 to 100.Male/Female:*MaleFemaleName of School that the child attends:*Grade:*Please enter a number from 1 to 12.Teacher's Name:Home Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Father's Name:*Father's Occupation:Father's Phone Number:*Mother's Name:*Mother's Occupation:Mother's Phone Number:*Referred by:* Family HistoryChild is living with (check all that apply):* Birth Father Birth Mother Step-Father Step-Mother Legal Guardian Other Please explain:*Check if applicable: Child is adopted Child is fostered Since the child's birth there has been:Check all that apply. Death in the family Separation Divorce Remarriage of Mother Remarriage of Father Other major trauma Please explain the reaction of the child:*Are there other children in the family?*YesNoIs there a history of learning difficulties in your family?*YesNoPlease explain:*Briefly describe your child's relationship with you, your spouse, and other members of the family:* Sibling #1:Name* First Last Age in years:*Use zero if the child less than a year old.Please enter a number from 0 to 100.Grade:Use zero if the child is in preschool or kindergarten. Please enter a number from 0 to 12.Present School:Are there additional children?*YesNoSibling #2:Name* First Last Age in years:*Use zero if the child less than a year old.Please enter a number from 0 to 100.Grade:Use zero if the child is in preschool or kindergarten. Please enter a number from 0 to 12.Present School:Are there additional children?*YesNoSibling #3:Name* First Last Age in years:*Use zero if the child less than a year old.Please enter a number from 0 to 100.Grade:Use zero if the child is in preschool or kindergarten. Please enter a number from 0 to 12.Present School:Are there additional children?*YesNoSibling #4:Name* First Last Age in years:*Use zero if the child less than a year old.Please enter a number from 0 to 100.Grade:Use zero if the child is in preschool or kindergarten. Please enter a number from 0 to 12.Present School:Are there additional children?*YesNoSibling #5:Name* First Last Age in years:*Use zero if the child less than a year old.Please enter a number from 0 to 100.Grade:Use zero if the child is in preschool or kindergarten. Please enter a number from 0 to 12.Present School:Are there additional children?*YesNoSibling #6:Name* First Last Age in years:*Use zero if the child less than a year old.Please enter a number from 0 to 100.Grade:Use zero if the child is in preschool or kindergarten. Please enter a number from 0 to 12.Present School:Are there additional children?*YesNoSibling #7:Name* First Last Age in years:*Use zero if the child less than a year old.Please enter a number from 0 to 100.Grade:Use zero if the child is in preschool or kindergarten. Please enter a number from 0 to 12.Present School:Are there additional children?*YesNoSibling #8:Name* First Last Age in years:*Use zero if the child less than a year old.Please enter a number from 0 to 100.Grade:Use zero if the child is in preschool or kindergarten. Please enter a number from 0 to 12.Present School:Are there additional children?*YesNoSibling #9:Name* First Last Age in years:*Use zero if the child less than a year old.Please enter a number from 0 to 100.Grade:Use zero if the child is in preschool or kindergarten. Please enter a number from 0 to 12.Present School:Are there additional children?*YesNoSibling #10:Name* First Last Age in years:*Use zero if the child less than a year old.Please enter a number from 0 to 100.Grade:Use zero if the child is in preschool or kindergarten. Please enter a number from 0 to 12.Present School: Medical/Developmental HistoryChild was:*Full TermPrematureState any complications which occurred during pregnancy (e.g., toxemia, diabetes, etc.):State any complications which your child had immediately after birth (e.g., difficulty breathing, blue color, etc.):Select all that apply:* Recent physical exam Recent eye exam Recent hearing exam Recent speech evaluation None Please state the approximate date(s) of the exam(s) and the result(s):*Check any problems in infancy or childhood with: Colic Sleeping Talking Bedwetting Crawling Eating Walking/running General slow development None Child: (check where applicable) Needs glasses Wears glasses has Allergies/asthma has/had Seizures, convulsions, or staring spells has/had High Fevers has/had Frequent ear infections has/had Hearing difficulties Experienced injury/accident to head None Please explain:* School HistoryChild is currently in:ElementaryJunior High/Middle SchoolHigh SchoolElementary SchoolName of Elementary School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional Elementary Schools to add?*YesNoReason for changing/leaving the aforementioned school:*Elementary School #2Name of Elementary School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional Elementary Schools to add?*YesNoReason for changing/leaving the aforementioned school:*Elementary School #3Name of Elementary School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional Elementary Schools to add?*YesNoReason for changing/leaving the aforementioned school:*Elementary School #4Name of Elementary School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional Elementary Schools to add?*YesNoReason for changing/leaving the aforementioned school:*Elementary School #5Name of Elementary School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:* Junior High/Middle SchoolName of Junior High/Middle School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional Junior High/Middle Schools to add?*YesNoReason for changing/leaving the aforementioned school:*Junior High/Middle School #2Name of Junior High/Middle School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional Junior High/Middle Schools to add?*YesNoReason for changing/leaving the aforementioned school:*Junior High/Middle School #3Name of Junior High/Middle School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional Junior High/Middle Schools to add?*YesNoReason for changing/leaving the aforementioned school:*Junior High/Middle School #4Name of Junior High/Middle School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional Junior High/Middle Schools to add?*YesNoReason for changing/leaving the aforementioned school:*Junior High/Middle School #5Name of Junior High/Middle School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:* High SchoolName of High School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Do you have additional High Schools to add?*YesNoReason for changing/leaving the aforementioned school:*High School #2Name of High School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional High Schools to add?*YesNoReason for changing/leaving the aforementioned school:*High School #3Name of High School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional High Schools to add?*YesNoReason for changing/leaving the aforementioned school:*High School #4Name of High School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:*Do you have additional High Schools to add?*YesNoReason for changing/leaving the aforementioned school:*High School #5Name of High School:*Location* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Grades Attended:* Additional Educational InformationChild writes with:* Right Hand Left Hand Uses both hands Mirror Writer Has the child repeated any grade(s)?*YesNoPlease list the grade(s):*Has the child ever received tutoring?*YesNoPlease list the subjects:*Has the child ever been enrolled in special classes?*YesNoPlease list the class type(s):*Has the child received physical/occupational therapy?*YesNoHave you received speech or language therapy?*YesNo State the child's BEST subject?*State the child's WORST subject?*Has the child been tested before?*YesNoDate*Please give the approximate day of the testing.Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Location of the testing:* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Has the child ever had a:* IEP 504 Plan Other accomodation None Please explain the accommodation:*Has the child been diagnosed with:* ADD ADHD Learning Disabled Other None Please explain:*Additional comments or information regarding school history:State the area(s) in which you feel your child needs help:* Social/Behavioral HistoryCheck all descriptions that apply to your child's social/behavior history: Independent Anxious Dishonest Shy Passive Lacks common sense Easily distracted Overly fearful Enjoys school Makes friends easily Stubborn Aggressive Withdrawn Moody Confident Dependent Complains about school Overly sensitive Self-centered Easily frustrated Prefers playing with much older children Prefers playing with much younger children Please list any additional information you would like to share before testing:I hereby give Joshua Institute consent to test my child.*YesCAPTCHA
