Steps with Theera

A Vocational Training Centre & Coffee Shop

Date

StudentInformation:

FullName
Nickname
DateofBirth
PlaceofBirth
Nationality
LanguagesSpoken
ApplyingforThaior
EnglishProgramme
Gender / Female / Male Gender Neutral
OtherChildreninthe
Family
(Namesand Age) /

Parent/GuardianInformation:

PrimaryCarerRelationshiptoStudent Address

Address

City

PostCode HomePhoneNumber MobileNumber

WorkNumber Email Occupation SecondaryCarer

RelationshiptoStudent SameasPrimaryCarer Address

Address

City

PostCode HomePhoneNumber MobileNumber

WorkNumber

Email

Occupation

PersontoContactinCase ofEmergency

RelationshiptoStudent

PreferredHospitalinCase ofEmergency

AdditionalStudentInformation:

Doesyourchildhavea diagnosis?Whenwasit made?(Pleaseprovideany reportsorstatements)

Ifyourchilddoesn'thavea medical/official diagnosis,whatdoyou believetheirneedstobe andwhy?

Doesyourchildtakeanymedication?IfsopleasegivedetailsofALLmedicationsandpurpose

(seizures,anxiety,behaviour,allergy)

Drug / Dosage / Purpose / Date Started

Hasyourchildbeen admittedtohospitalfor anysurgeries/prolonged stays?(Pleasegivedetails)

Doesyourchildhaveany specialdietary requirements?

Whatdoesyourchild enjoydoing?Whatare

theygoodat?(academicor nonacademic)

Howwouldyoudescribe yourchildasaperson? (happy,easygoing, enthusiastic,inquisitive)

Whatkindofthingsscare orworryyourchild?

Highlight your child’s strengths/achievements and share anything you are particularly proud of them achieving.

Pleasetickanyofthefollowingthingswhichconcernyouaboutyourchild.

Anyotherconcernsor comments?

Doesyourchildhavea behaviourplanorany behaviourconcerns?

Howisyourchild disciplinedfornegative behaviourandhowdo theyrespond?

Isthereanycircumstance underwhichwewouldsee yourchildbeviolent? Pleasedescribeindetail.

Doesyourchildhaveany tics,repetitivemovement patterns,fixationsorself stimulatorybehaviours?

Describeanyissuesor historyofdifficulties aroundsexuality.

Describeyourchild'sself careandtoiletinghabits (teethbrushing,washing, gettingdressed,toilet trainedetc)

HasyourchildhadSpeech andLanguageTherapy/ OccupationalTherapy/ Counselling/ABA/any othertherapy?Pleasegive asmuchinformationas possible.(Pleaseprovide anyreports/assessments)

Wouldyoulikeyourchild toseeourSpeech Therapist/Occupational Therapist/Counsellor?

Howdoesyourchild communicate?Describe theircommunication (verbal,sign,AAC)

Haveyounoticedany regressioninyourchild? (Pleaseindicatewhen/ details)

Whatareyour expectationsfromour programme?

Whatdoyouenvisagefor yourchild'sfuture?What wouldyoulikethemto achieve/beabletodo?

Inthefuture,weplanto openasemiindependentlivingprogramme,would youbeinterestedinthis?

Arethereanyother servicesyouwouldbe interestedin?

ParentDeclaration

InmakingthisapplicationI/Weundertakeandagree:

•ThatcompletionofthisformdoesnotguaranteeanofferofaplaceatStepswithTheera

•Toprovideacopyofmy/ourchild’smostrecentschoolreport/assessmentatthetimeof

enrolment

•Topayanenrolmentfeeof25,000bahtifapplicationissuccessful

•Topayalldueprogrammefeespriortothecommencementofeachquarter(datesprovidedon

invoice)

•Togivenwrittennoticeofyourchildwithdrawingfromtheprogrammewithatleast3months

notice

Indemnity

•I/WeherebyindemnifyStepswithTheeraandit'semployeesagainstanyandallclaimsarising fromanyinjurytomychildwhistparticipatinginanyactivity,whetheronStepswithTheeraproperty,whiletravelingtoorfromStepswithTheerapremises,orwhileonaprogrammevisitor outing.

• I/Weunderstandandagreethatintheeventofanemergency,StepswithTheerawillmakeevery efforttocontacttheparentsorguardian.However,if thisis notpossible,thepupilwillbetakento SukhumvitHospital

Pleasesignbelow: Signature:

PrintName:

Igiveconsentfor:

•Informationsharedinthisformtobesharedwithotherprofessionalswhowillworkwithmy childand/orinputintotheirprovision

PrintName: Signature:

Igiveconsentfor:

•Photosofmychildtobeusedonourwebsite,inmagazines,inmarketingmaterialsand/oron socialmedia

Signature: PrintName:

Thissectionistobecompletedbythestudentthemselves(wherepossible)

Whatdoyouliketolearnabout?Example- transport,nature, dinosaurs,technology.

Whatdoyoulikedoingin yourfreetime?Example- playingiPad,hangingout withfriends,art,football.

Doyoufeellikeyouare readytostartworkingand beingmoreindependent?

Whatwouldyoudream jobbe?Example- magician,popstar, computergamedesigner.

Whatskillsdo youthink youwilllearnworkingin acoffeeshopandbakery?

Example-howtomake coffee.

Doyouhaveanyspecial skillsyouthinkwillbe usefulatwork?Example- Iamgoodattalkingto people.

StudentDeclaration

IpromisetofollowtherulesofStepswithTheera,worktomyfullpotentialandtotrymybestto haveapositiveattitudeeveryday.

Igivepermissionfor:

•MyinformationtobesharedwiththeteachersandstaffatStepswithTheera

•Myphotostobesharedonourwebsite,inmagazines,inmarketingmaterialsand/oronsocial

media

Signature: PrintName: