RCE FoundationFamily Grant Application Child Information: Parent/Legal Guardian: Health and Medical Information What are your primary concerns regarding your child’s speech, language, gross motor, fine motor or sensory development? Pregnancy and Birth History (circle responses): Did mother have any illnesses or complications during pregnancy or delivery? YesNo Any medications, alcohol, or other drug use during pregnancy? YesNo Was the birthing process natural or C-section? YesNo At how many weeks gestation was the child born? Did your child pass their newborn hearing screening? YesNo Did your child require hospital stay or time in the NICU? YesNo Did your child require any medical procedures before, during, or after birth? YesNo Was there any complication with bottle or breast feeding? YesNo Was your child bottle fed or breast fed and for how long? YesNo Did your child have any colic or reflux issues? YesNo Please describe illnesses, medical issues, or hospitalizations that your child has had and when? Has your child seen any specialists, or had any other evaluations/testing? (Please indicate which specialist) Are there any other precautions we should know about that are not already described? Does your child have/had any of the following medical conditions? ADD/ADHDAllergiesAsthmaAutismBalanceDifficultiesAsthmaCancerChicken PoxEar PainEar RingingExposure to Loud NoisesGenetic DisorderMotor ProblemsHeart ProblemsHead Trauma/injuryKidney ProblemsMeaslesPsychiatric DisorderSeizuresMumps Developmental Milestones: Please indicate if you have or have not observed.If so, when? Explain. Roll OverYesNo Sit UpYesNo CrawlYesNo WalkYesNo Drink from a cup:Sippy CupStrawOpen Cup Feed Self:FingersSpoonForkKnife Toilet Trained (check all that apply):IndependentFully DependentNeeds to be wipedIncontinent - cleans selfRequires Prompting/verbal cueing to use restroomNeeds physical assistWears UnderwearWears PullupsWears diapers ConstipationAt timesMild/ModSevere Self Help *Please indicate level of assistance child needs for the following, please note any concerns* Eating:IndependentMinimalModerateMaximumDependent Dressing:IndependentMinimalModerateMaximumDependent Bathing:IndependentMinimalModerateMaximumDependent Washing Hands:IndependentMinimalModerateMaximumDependent Washing Face:IndependentMinimalModerateMaximumDependent What is your child’s primary mode of mobility? Do they have any physical limitations/restrictions? Does your child have any dietary restrictions or specialized diets including minimum caloric intake standards? Also any difficulties with feeding such as picky eaters. What else should we should know about your child? Is your child currently on any medications? If yes, please list below. Medication Name Dosage Route Taken Frequency Possible Reactions Does your child require any equipment/devices? If yes, please check all that apply. Areas Yes/No Comments/Concerns Follows verbal directions YesNo Initiates conversations YesNo Makes eye contact when speaking YesNo Has safety awareness YesNo Impulsive/risk taker YesNo Displays aggression or rough play towards self/others YesNo Enjoys parallel and joint play with other children YesNo Is your child reluctant to wear or use these items? Does your child remove these items at will? Has your child received therapy services with a previous therapy company within the last six months?YesNo If yes, What services were received: Company Name: Address: Phone: Fax: Please Provide copies of the Original Evaluation, most recent Progress Reports, and Plan of Care Primary Insurance Policy # Group # Behavior and Social Skills Does your child have tantrums? YesNo If yes, how often? Does your child calm quickly? YesNo Any behavioral concerns we should know about? How do you handle discipline issues at home? What are used for motivators or incentives for positive behavior at home or at school? Does your child tend to play alone or with others? Previous Education PublicPrivateHomeschooledNo previous educational history Name of previous school: County: Previous teacher's name: Phone: Email: Years of attendance at this school: IEP504 Expiration date Psychoeducational Evaluation Therapies or accommodations within the classroom?YesNo Comments: Do you have any academic concerns? All Members in the house hold: Is your Adjusted Gross Income (AGI), as documented on your most recent IRS Tax Form 1040, at or under the following limits based on your family size? YesNo Please see table below: • Family Size of 2 -- $55,000 or less • Family Size of 3-- $85,000 or less • Family Size of 4-- $115,000 or less • Family Size of 5 or more-- $145,000 or less What is being requested from the RCE Foundation? What benefit would the above request have for your child/family? What benefit would the above request have for your child/family? Thank you for taking the time to complete this application! Authorization I certify that the information in this application is complete and accurate. Child’s Name: Parent/guardian printed name & relation: Parent/guardian signature: Date:
