Hope Montessori - Autism Class Application Form

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Autism Class Application Form

DATA PROTECTION AND FREEDOM OF INFORMATION

WE, THE MANAGEMENT OF HOPE MONTESSORI AUTISM CARE CENTRE WILL TREAT ALL
INFORMATION AND PERSONAL DATA YOU GIVE US AS CONFIDENTIAL. WE WILL NOT
DISCLOSE IT TO ANY OTHER PERSON OR BODIES WITHOUT YOUR PERMISSION.

Location you are applying for

Parent's Detail

MR.

MRS.

OTHER

Parent's Surname*

Parent's First Name*

Address*

Telephone*

Email*

Child's Detail

Child's Surname*

Child's First Name*

Select Gender

Relationship To You*

Date of Birth*

Please give the following details about your child

Child's Diagnosis*

Current or Previous Placement*

Communication (e.g. difficulty speaking or understanding making his/her needs known):*

Feeding*

Behavioural Traits (e.g sensory obsessions)*

Practical/Daily Living Skills*

Social Skills (e.g. eye contact responding to name playing with peers)*

Toileting*

Medical Information (e.g. taking tablets or Medicines home treatment programmes)*

Please set out the details of any other care and attention needed by the child

Do not enter anything in this field:

* indicates a required field

Please fill this field.

Mount View - Dublin 15

Monday 8:30 am – 6:00 pm
Tuesday 8:30 am – 6:00 pm
Wednesday 8:30 am – 6:00 pm
Thursday 8:30 am – 6:00 pm
Friday 8:30 am – 6:00 pm
Saturday Closed
Sunday Closed

Fortlawn - Dublin 15

Monday 8:30 am – 6:00 pm
Tuesday 8:30 am – 6:00 pm
Wednesday 8:30 am – 6:00 pm
Thursday 8:30 am – 6:00 pm
Friday 8:30 am – 6:00 pm
Saturday Closed
Sunday Closed

Inchicore -Dublin 8

Monday 8:00 am – 6:00 pm
Tuesday 8:00 am – 6:00 pm
Wednesday 8:00 am – 6:00 pm
Thursday 8:00 am – 6:00 pm
Friday 8:00 am – 6:00 pm
Saturday Closed
Sunday Closed

Limerick

Monday 8:00 am – 6:00 pm
Tuesday 8:00 am – 6:00 pm
Wednesday 8:00 am – 6:00 pm
Thursday 8:00 am – 6:00 pm
Friday 8:00 am – 6:00 pm
Saturday Closed
Sunday Closed

Cork

Monday 8:00 am – 6:00 pm
Tuesday 8:00 am – 6:00 pm
Wednesday 8:00 am – 6:00 pm
Thursday 8:00 am – 6:00 pm
Friday 8:00 am – 6:00 pm
Saturday Closed
Sunday Closed

OUR CHILD SECTOR PARTNERS
SMP - Childcare Software

HOPE PORTAL

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