Réaltaí- Application Form-Special Class for Autism - St Patricks BNS

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Réaltaí- Application Form-Special Class for Autism

Admissions and Enrolment

Application Form - Special Class for pupils with ASD

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  - Réaltaí           Year of Entry: September 2022 Mother/Guardian Name:__________________        Father/Guardian Name:  _________________ Mother’s Telephone No: __________________        Father’s Telephone No: __________________ Mother’s Email Address: ___________________     Father’s Email Address: ___________________

Current Educational Setting: Name of Early Intervention Setting / Pre-School Setting / Mainstream Primary School Setting & how many years your child has been in that setting: _______________________________________________________________________________________________________________________________________________________________ _____________        Required Reports
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-Disciplinary Assessment Report. This report must be current and must include a recommendation that a placement in a special class in a mainstream school is both necessary and suitable for the child.
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.

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