Student Application for Testing and/or Educational Services Step 1 of 6 - General Information 0% General InformationName of Student:* First Last Nickname/Name Preferred:Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age:*Please enter a number from 1 to 100.Male/Female:*MaleFemaleName of school your child currently 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 Father's Name:* First Last Father's Occupation:Father's Phone Number:*Father's Email Address:* Mother's Name:* First Last Mother's Occupation:Mother's Phone Number:*Mother's Email Address:* Referred by: First Last Emergency Contact:* First Last Relationship:*Emergency Contact's Phone Number:* Permission for Cognitive and/or Academic TestingConsent:* I give permission to Joshua Institute to test my son/daughter.Please select one from the drop down menu:*PLEASE NOTE: For us to best understand where your child is academically and cognitively, Academic Testing should not be more than 1 year old, and Cognitive Testing should not be more than 3 years old.Testing NeededNo further testing is needed; I will upload my student's current test results below.Which test(s) does your student need?* Cognitive Ability - $450 Academic Achievement - $325 Full payment (cash or check) is due with the submission of this application.*Please mail or drop off payment at: Attn: Britt Collingwood Joshua Institute 2150 W. Cherry Lane Meridian, ID 83642 If you have any questions, please call (208)-893-5130 or email bcollingwood@joshuainstitute.org. I agree to pay the amount above in full upon submission of this application.Current Testing ResultsPlease upload your student's current test results, if any:Accepted file types: pdf, png, jpg, docx. Family HistoryChild is living with (check all that apply):* Birth Father Birth Mother Stepfather Stepmother Legal Guardian Other 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 life events or trauma Please explain the reaction of the child:*Are there other children in the family?*YesNoPlease list any other children in the family, their age, and the school they currently attend.*Is there a history of learning difficulties in your family?*YesNoIf yes, please explain:*Briefly describe your child's relationship with you, your spouse, and other members of the family:* Medical/Developmental HistoryChild was:*Full TermPrematureState any complications which occurred during pregnancy (e.g. toxemia, diabetes, etc.):*State any complications your child had immediately after birth (e.g. difficulty breathing, blue color, etc.):*My student has had the following within the last year (please check all that apply):* Physical exam Eye exam Hearing exam Speech evaluation None Please list the approximate dates and results of the test(s).*Please check the following if your student had 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:* Educational HistoryChild is currently in:*ElementaryJunior high / Middle schoolHigh schoolPlease list ALL schools previously attended (preschool to present), the grade(s) your student was in, and the reason for changing schools.*Child 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?*YesNoHas the child received speech or language therapy?*YesNoWhat is your child's BEST subject?*What is your child's WORST subject?*Child has been tested before (other than Cognitive and Academic testing):* Yes No If yes, please give type of test, date and location of testing:*Has the child ever had a/an:* IEP 504 Plan Other accomodations None Please upload these documents: Drop files here or Accepted file types: pdf, png, jpg, docx. Please explain the accommodation:*Has the child ever 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/behavioral 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:
