Application Form -
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Pupil’s Name (As per Birth Cert): ______________________________________________________ Address:___________________________________________________ Eircode: ______________
Date of Birth: __________________ P.P.S.N: ________________
Nationality: ____________________ Religion: ________________
Proposed class: Special Class for Pupils with ASD -
Current Educational Setting: Name of Early Intervention Setting / Pre-
Each child applying for a place in the special class for pupils with ASD, must have a diagnosis of Autism/ Autistic Spectrum Disorder using DSM V or ICD 10 criteria as set out by a professional/individual approved by the Department of Education and skills and a Multi-
Please attach this report to this application. Please also attach all other relevant supporting documents – other reports from professionals, schools etc.
Signature of Parent/Guardian ___________________________ Date: ________________
Signature of Parents/Guardian ___________________________ Date: ________________
The data contained in this form will be stored and used for the purpose of this application only. If your child is offered a place, a Birth Certificate and an Enrolment form with further information data/information will be required on enrolment. Baptismal Certificates with be required only for pupils making First Holy Communion.