Downloadable Admission FormPlease fill in the admission form below, else download the admission form and send the filled copy to ace@ace-india.org Contact InformationParents contact number *Email address *Residential Address * Child's InformationChild's Name *Date Of Birth *Gender *MaleFemalePrimary language of child (if child is verbal) Medical InformationDiagnosis by (Doctor/Hospital): *Diagnosis *ASD/AutismADHDGlobal Development Delay (GDD)PDD-NOS (Pervasive Developmental Delay- Not otherwise certified)OtherAge of child at time of diagnosis *Medical Conditions (If any comorbidity) Parent's Information-MotherName *Highest Level Of Education Completed GraduationPost GraduationMetriculationOtherName of organization (put N/A if not working outside home) *Designation Gross Monthly Income *Above INR 5,00,000INR 3,00,000-5,00,000INR 1,00,000-3,00,000INR 50,000-1,00,000Less than INR 50,000 Parent's Information-FatherName *Highest Level Of Education Completed GraduationPost GraduationMetriculationOtherName of organization (put N/A if not working outside home) *Designation Gross Monthly Income *Above INR 5,00,000INR 3,00,000-5,00,000INR 1,00,000-3,00,000INR 50,000-INR 1,00,000Less than INR 50,000 Primary Contact DetailsWho will be the primary contact? *FatherMotherOtherSpecify if other Parents Marital Status *MarriedSingleSeparatedWidowe(r)Person assigned legal custody (only if divorced) FatherMotherOther Family InformationNumber of siblings of the child *012Other Child Health InformationList any serious illnesses or hospitalizations Current medication(s) *Past medications Has your child been given all the required vaccinations? *YesNoDoes your child have food/environmental allergies? *YesNoDoes your child have constraints for physical activities? *YesNoIs your child on a special/restricted diet? *YesNoDoes your child have problems with (check all that apply) *ChewingSwallowingChokingRefusal to eatExcessive IntakeIngesting non-food itemsNone of the aboveDoes your child have other health needs that ACE needs to be aware of? General informationIs your child toilet trained? *YesNoIs your child able to dress on his/her own? *YesNoIs your child able to bath on his/her own? *YesNoIs your child able to brush his/her teeth? *YesNoDoes your child sleep through the night? *YesNoHow does your child communicate?(Select all/any that apply) *VerbalSignsPECS / picturesGesturesComputer AppsOtherSpecify if other What are your child's favourite foods? *Which types of activities does your child enjoy doing with you at home? * Educational InformationName and location of current centre/school *What are your top priorities from ACE’s programme? (Please check all that apply) *Communication and speechAcademicsSocializationLife skills developmentBehaviors managementSensory and motor skills developmentOtherSpecify if other What special education services / early intervention services has your child received so far? *Speech TherapyOccupational TherapyPhysical TherapySpecial Education / InterventionABANoneOtherSpecify if other Please list previous educational programme/therapy attended by your child Additional informationIs there anything else you would like us to know about your child? How did you learn about ACE? *GoogleSocial MediaAnother parentNewspaperACE awareness eventOther Please enter a numerical valueExample: 12This box is for spam protection - please leave it blank: Downloadable Admission Form
