KPRDSB Group Services Interest Form

I am/ my child or teen is registered in a KPRDSB School:*

Yes
No

Please select the age group you are interested in:*

Please select the group(s) you are interested in:*

Kids Klub: February 28 – April 24 (no class March break) Wednesdays, 4:30 – 5:30pm
Kids Klub: May 1 – June 19, Wednesdays, 4:30 – 5:30pm

Please select the group(s) you are interested in:*

Friendship Crew: February 29 – April 25 (no class March break), Thursdays, 4:30 – 5:30pm
Bully Proofing Crew: April 30 – June 18, Tuesdays, 4:30 – 5:30pm

Please select the group(s) you are interested in:*

AIM 1: February 26 – April 29 (no class March break, April 1), Mondays, 4:30 – 5:30pm
AIM 2: May 2 – June 20, Thursdays, 4:30 – 5:30pm

Please select the delivery format you are interested in:*

Virtual (offered online only)

Participant Information

Participant First Name:*

Participant Last Name:*

Date of Birth (DD/MM/YYYY):*

Age:*

Siblings:*

Yes
No

If "Yes", please specify the sibling age(s):

School*

School Board*

Grade*

Placement Type:

Mainstream (no support)
Mainstream (with support)
Part-time learning centre
Community/county - Autism Spectrum Disorder (ASD)
Community/county - Developmental Disabilities
Other

If "Other", please specify:

Have you previously participated in a group or a group sample session at Kinark?*

No
Yes - group sample session only
Yes - I have participated in a group at Kinark

If you have participated in a group at Kinark, please let us know the name(s) of the group:

Are you currently receiving any other services at Kinark?*

Yes
No

If 'Yes', please specify:*

Contact Information

Who should we contact with information about the group(s) and next steps?:*

Participant
Parent/Caregiver

First Name:

Last Name

Email*

Phone Number:*

Preferred Contact Method*

Address*

If another individual/caregiver may be involved, please list their full name, relationship to the participant, contact information, and any other relevant details:

Participant Profile

I am/ my child or teen is (please select all that apply):*

motivated to participate in a group
motivated to interact with peers (vs. avoiding social interactions)

Communication (please select one):*

Speaks fluently in full sentences and can discuss events that happen in the past or future
Speaks in full sentences but may need support with extended discussions or reciprocal conversations
Speaks in two or three word phrases
Speaks in single words
Uses an alternative communication (e.g., sign language, picture exchange communication system, communication device)
Has no formal mode of communication (e.g., cries, pulls, points, pushes)

Independence and Attention (please select one):*

Can follow along with a group independently for 45 to 60 minutes (with breaks)
May need some additional parent/adult prompting and/or modeling
Will require one-to-one support to attend and/or participate

If one-to-one support is required, please describe what the support would be for:*

Some behaviours may make it challenging to participate in a group, or may be disruptive to group participation (e.g., physical or verbal aggression, self-injury, property destruction). Do you/your child have any behaviours that may hinder group learning?*

Yes
No

If yes, please describe what the behaviours may look like:*

Where are these behaviours observed? (ie: at home only, at school only, in the community only, at both home and school, etc...)*

Please list any health conditions that may interfere with group participation (e.g., seizure disorder, anaphylaxis, anxiety, depression):

What are some of your/your child or teen’s topics of interest or preferred activities?

Do you have any suggestions to improve your/your child or teen’s success with a group program?

Please share any additional information/comments/questions that you may have here:

Parent/Caregiver Participation

Please complete this section if a social coach/parent/caregiver is involved.

I am able to (please select all that apply):

attend a parent orientation session for an overview of the group and to review group expectations
attend ongoing parent education sessions and help my child/teen with homework activities to practice the skills learned

Technology Requirements

Do you have adequate internet connectivity (i.e., high-speed internet with sufficient bandwidth) and access to appropriate technology (e.g., a computer/laptop/tablet) which supports video conferencing (i.e., have a microphone, speakers, and a webcam)?*

Yes
No

Would you be using a password-protected, secure internet connection to join the group (vs. public or unsecured Wi-Fi)?*

Yes
No

How did you learn about this service? (Please check all that apply)

Please specify the community event:*

Please specify the agency/organization:*

Please specify the conference:*

If “other,” please specify:*

Do you want to be added to our mailing list to receive information about our programs and services?*

Yes
No

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KPRDSB Group Services Interest Form