ELIS Application Form

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ELIS Application Form

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ELIS Application Form

The Early Learning Intensive Support (ELIS) is a program for young children who require intensive support to meet their potential. This application form is intended for families with children with intensive needs.

It is important for you to understand that submitting an application does not guarantee your child a spot in a program.

If your child was born in 2020 or 2021, please submit your application for PreK for the 2024-2025 school year. Students are eligible to begin PreK once they turn 3.
If your child was born in 2019, please register for Kindergarten for the 2024-2025 school year.

*The information provided will be used for the purposes of determining your child's eligibility to participate in the Early Learning Intensive Support (ELIS) Pilot Program.
* Following receipt of the application you will be contacted to gather additional information and discuss options for your child.
* Students who are accepted into the ELIS program may be offered a spot at a school outside of their catchment area.
*** Please note that transportation is the responsibility of the family.***
If you have any questions, contact the Early Learning Consultant, Tammy Grieve

Application:

Catchment Area School:*

Previous School Attended:

PSS Catchment Area Map

Background Information:

Legal Name of Child:*

Legal First Name: Legal Middle Name: Legal Last Name:

Name Used (if different than legal name):

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

MM slash DD slash YYYY

Gender:*

Female

Male

Undeclared

Home Phone Number:*

Child's current address is a:*

Street Address

P.O Box Number

Home Address:*

Street Address Apartment Number City / Town Province Postal Code

Home Address:*

If the mailing address is a box number, please also provide a physical address and/or land location.

P.O Box Number City / Town Province Postal Code

Land Location:

1/4 Section:

Section:

Township:

Range Road:

Meridian:

How long has the child been at this address*

Citizenship:

First Citizenship:*

Second Citizenship (if applicable)

Second Citizenship:

Birth Country:*

Country of Origin:*

Saskatchewan resident?*

Yes

No

What languages are spoken in the home:*

Add another spoken language

Second language spoken in the home:

What is your child's first language:*

At what age did your child begin to speak their first language:*

Translation services required:*

Yes

No

If your child's first language is not English, at what age did they begin to speak English:

Parent(s)/Guardian(s) Contact Information

First Parent/Guardian Contact Information:

Name*

First Name Last Name

Relationship to Child - please specify:*

Parent/Guardian Home Phone:*

Parent/Guardian Cellular Phone:

First Parent/ Guardian's current address is a:*

Street Address

P.O Box Number

Street Address:*

Street Address Apartment Number City / Town Province Postal Code

Home Address:*

If the mailing address is a box number, please also provide a physical address and/or land location.

P.O Box Number City / Town Province Postal Code

Land Location:

1/4 Section:

Section:

Township:

Range Road:

Meridian:

How long have you been at this address:*

Daytime Commitment (Name of workplace):

Parent/Guardian Work Phone:

Level of Education:

Email Address:

Add another Parent/Guardian contact

Second Parent/Guardian Contact Information:

Name*

First Name Last Name

Relationship to Child - please specify:*

Parent/Guardian Home Phone:

Parent/Guardian Cellular Phone:

Second Parent/ Guardian's current address is a:*

Street Address

P.O Box Number

Street Address:*

Street Address Apartment Number City / Town Province Postal Code

Home Address:*

If the mailing address is a box number, please also provide a physical address and/or land location.

P.O Box Number City / Town Province Postal Code

Land Location:

1/4 Section:

Section:

Township:

Range Road:

Meridian:

How long have you been at this address:

Daytime Commitment (Name of workplace):

Parent/Guardian Work Phone:

Level of Education:

Email Address:

Child lives with (List all, specify):*

Is there a legal custody arrangement:*

Yes

No

If yes, Who has legal custody: (Please share legal documentation upon admittance to the program)

Daycare/Babysitter Contact:

Daycare or child care provider name:

Licensed:

Yes

No

Daycare/Babysitter Address:

Street Address Apartment Number / P.O Box City Province Postal Code

Daycare/Babysitter Home Phone Number:

Daycare/Babysitter Cellular Phone Number:

Daycare/Babysitter Business Phone Number:

Has your child been involved with other childcare programs (i.e. Daycare, Private Pre-school, Early Learning Centre, Head Start, etc.)*

Yes

No

if Yes, Provide list:

Does your child receive Enhanced Accessibility Grant Funding:*

Yes

No

Emergency Contact Information:

Who should be contacted in case of an emergency if parent(s)/guardian(s) cannot be reached?

(Emergency contact should be someone who is in close proximity to the school and can be contacted if the parents are unavailable)

First Emergency Contact Name:*

First Name * Last Name *

First Emergency Contact Phone Number*

First Emergency Contact Relationship:*

Add another emergency contact

Second Emergency Contact Name:*

First Name * Last Name *

Second Emergency Contact Phone Number

Second Emergency Contact Relationship:

Add another emergency contact

Third Emergency Contact Name:*

First Name * Last Name *

Third Emergency Contact Phone Number

Third Emergency Contact Relationship:

Voluntary Indigenous Self Declaration:

Overview

Parent(s)/guardian(s) are asked to identify their children/students as being Indigenous (First Nations, Inuit, Métis), or of non-Indigenous ancestry, during the registration process. The choice to identify is voluntary and confidential.

Privacy

This information is stored electronically and in paper form, in the student’s cumulative file. It is secure and access is limited to Prairie South and the SK Ministry of Education. All employees within Prairie South Schools are to adhere to Administrative Procedure 180 “Guidelines for Protecting the Privacy and Confidentiality of Personal Information” and “Local Authority Freedom of Information and Protection of Privacy (LAFOIP)”.

Why self-declare?

Some individuals may be hesitant to self-declare as an ethnic group member for fear of being marginalized or because of past experiences. Information on a self-declaration form is used solely to help define programming and services to assist in the success and achievement of Indigenous students in and throughout their schooling experience. “Being proud of our culture and history impacts student confidence and creates a stronger sense of belonging” (Living Sky School Division, 2020).

The Canadian Constitution recognizes three distinct groups of Indigenous people.

First Nations / Registered / Treaty / Status (refers to an individual recognized by the federal government as being registered under The Indian Act)

First Nations / Non-Registered / Non-Status (refers to a First Nations person who is not registered under The Indian Act)

Métis (refers to a person of mixed First Nations and European ancestry who identifies as Métis, as distinct from First Nations, Inuit, or non-Aboriginal)

Inuit (refers to a person who identifies as Inuit, as distinct from First Nations, Métis, or non-Aboriginal)

Please check the box that best identifies your child: **

Please check the box that best identifies your child: *

First Nations / Registered / Treaty / Status

First Nations / Non-Registered / Non-Status

Métis

Inuit

Non-applicable

Siblings:

Does this child have at least one sibling?*

Yes

No

First Sibling Information:*

First Sibling Information:

First * Last *

First Sibling Current School:

Age:*

Other school:

If you selected "Other school not listed here" in the Current School selection above, please specify the school name here.

Add another sibling

Second Sibling Information:*

Second Sibling Information:

First * Last *

Second Sibling Current School:

Age:

Other school:

If you selected "Other school not listed here" in the Current School selection above, please specify the school name here.

Add another sibling

Third Sibling Information:*

Third Sibling Information:

First * Last *

Third Sibling Current School:

Age:

Other school:

If you selected "Other school not listed here" in the Current School selection above, please specify the school name here.

Add another sibling

Fourth Sibling Information:*

Fourth Sibling Information:

First * Last *

Fourth Sibling Current School:

Age:

Other school:

If you selected "Other school not listed here" in the Current School selection above, please specify the school name here.

Health History:

Child's Birth Weight: (indicate lb or kg)*

Please list any problems during pregnancy with this child, at birth, or immediately after birth:

Has your child had frequent earaches or infections:*

Yes

No

Does your child wear a hearing aid:*

Yes

No

Has your child ever had, or do they currently have tubes in their ears:*

Yes

No

Does your child use sign language?*

Yes

No

If Yes, Please explain:

Has your child's hearing been tested by an audiologist:*

Yes

No

Test Date (MM/DD/YYYY):

MM slash DD slash YYYY

Detail:

Does your child have any allergies:*

Yes

No

if Yes, Please List

Does your child have food restrictions:*

Yes

No

if Yes, Please List

Does your child use an inhaler, EpiPen:*

Yes

No

if Yes, Please List

Does your child take medication:*

Yes

No

if Yes, Please List

Has your child's vision been tested by an Optometrist:*

Yes

No

Test Date (MM/DD/YYYY):

MM slash DD slash YYYY

Does your child wear glasses or use other visual devices:*

Yes

No

if Yes, when (at all times, classroom only)

Does your child use Braille?*

Yes

No

Has your child received their dental check-up:*

Yes

No

Check-up Date (MM/DD/YYYY):

MM slash DD slash YYYY

Does your child have a diagnosed disability or medical condition:*

Yes

No

if Yes, please explain:

Early Learning Behaviours and Experiences:

Is your child shy:*

Yes

No

Is your child withdrawn:*

Yes

No

Is your child aggressive:*

Yes

No

Does anything worry you about how your child plays:*

Yes

No

if Yes, please explain:

Does your child have an opportunity to play and interact with other children:*

Yes

No

if No, please explain:

Does anything worry you about how your child shows their feelings:*

Yes

No

if Yes, please explain:

Does anything worry you about how your child learns:*

Yes

No

if Yes, please explain:

Does anything worry you about how your child behaves:*

Yes

No

if Yes, please explain:

Toileting:*

Your child is not required to be potty trained to be considered for ELIS.
In order to support your child's independence/ toileting needs, please indicate their level of independence when it comes to toileting.

Unaware/ Unconcerned if Wet/ Soiled

Wearing diapers, but showing early bladder control, can go 2 or more hours without needing to be changed

Communicates verbally or physically a dislike of being wet/ soiled and/or the desire to be changed

Wearing diapers, will go into the bathroom (wash hands etc. but will not use the toilet)

Wearing pull-ups, will go into the bathroom and sit, but not use it, needs to be changed

Wearing pull-ups, and will sometimes use the toilet to pee

Wearing pull-ups, and will sometimes use the toilet to pee and for bowel movements

Wearing underwear, needs reminders and some assistance.(still has frequent accidents)

Wearing underwear, is independent in the bathroom, rarely has accidents, may need a little help with wiping or clothes

Wearing underwear, is independent in the bathroom

Comments:

Can your child feed themselves:*

Yes

No

Can your child dress themselves:*

Yes

No

Does your child have food and/or texture preferences?*

Yes

No

If Yes, please explain:

Does your child ask for assistance:*

Yes

No

Does your child separate easily from you:*

Yes

No

Has your child experienced or witnessed traumatic events that you feel might have an effect on your child's learning (i.e. life threatening illness, violence, death of a loved one, accident, fire, family break-up, or other trauma):*

Yes

No

if Yes, please explain:

Speech

Do you have difficulty understanding your child's speech:*

Yes

No

Do others have difficulty understanding your child's speech:*

Yes

No

Does your child have difficulty expressing themselves:*

Yes

No

Can your child follow a one-step direction such as, "get your ball, it is by the door":*

Yes

No

Can your child follow a two-step direction such as, "go to your room and get your coat that is under your bed":*

Yes

No

Does your child use words:*

Yes

No

Does your child use sentences:*

Yes

No

When your child speaks, do their responses make sense:*

Yes

No

if No, please explain:

Please outline the strengths and needs of your child in the following areas:

Mobility: Describe how your child moves from one place to another:*

Scooting

Walking

Crawling

Wheelchair

Lifting required:*

Yes

No

Weight of child: (indicate lb or kg)*

Physical development (like running and jumping, holding a crayon, catching a ball or using a spoon)

Medical Needs: (eg. oxygen, g-tube fed, seizures? etc)

Sensory Needs: (sounds, lighting, touch, smell, etc.)

Is there anything else you would like to share about your child and/or family?

Service Providing Agencies:

Kids First*

Yes

No

Contact Person:

Contact Phone Number:

KF_options

Referral

Weekly

Monthly

Yearly

*Report Available

YMCA*

Yes

No

Contact Person:

Contact Phone Number:

ymca_options

Referral

Weekly

Monthly

Yearly

*Report Available

Mentor*

Yes

No

Contact Person:

Contact Phone Number:

mentor_options

Referral

Weekly

Monthly

Yearly

*Report Available

ECIP*

Yes

No

Contact Person:

Contact Phone Number:

ecip_options

Referral

Weekly

Monthly

Yearly

*Report Available

ASD*

Yes

No

Contact Person:

Contact Phone Number:

asd_options

Referral

Weekly

Monthly

Yearly

*Report Available

Speech*

Yes

No

.

Private

Public

Contact Person:

Contact Phone Number:

speech_options

Referral

Weekly

Monthly

Yearly

*Report Available

Occupational Therapist*

Yes

No

Contact Person:

Contact Phone Number:

ot_options

Referral

Weekly

Monthly

Yearly

*Report Available

Physical Therapist*

Yes

No

Contact Person:

Contact Phone Number:

pt_options

Referral

Weekly

Monthly

Yearly

*Report Available

Wascana*

Yes

No

Contact Person:

Contact Phone Number:

wascana_options

Referral

Weekly

Monthly

Yearly

*Report Available

Child & Youth Services*

Yes

No

Contact Person:

Contact Phone Number:

ss_options

Referral

Weekly

Monthly

Yearly

*Report Available

Early Childhood Psychologist*

Yes

No

Contact Person:

Contact Phone Number:

echp_options

Referral

Weekly

Monthly

Yearly

*Report Available

Hearing Specialist*

Yes

No

Contact Person:

Contact Phone Number:

HS_options

Referral

Weekly

Monthly

Yearly

*Report Available

Vision Specialist*

Yes

No

Contact Person:

Contact Phone Number:

vs_options

Referral

Weekly

Monthly

Yearly

*Report Available

Cognitive Disability Strategy*

Yes

No

Contact Person:

Contact Phone Number:

cd_options

Referral

Weekly

Monthly

Yearly

*Report Available

Other*

Yes

No

Contact Person:

Contact Phone Number:

other_options

Referral

Weekly

Monthly

Yearly

*Report Available

ELIS (Early Learning Intensive Supports)

For more information contact Early Learning Consultant Tammy Grieve

*The information provided will be used for the purposes of determining your child's eligibility to participate in the Early Learning Intensive Support (ELIS) Pilot Program.
* Following receipt of the application you will be contacted to gather additional information and discuss options for your child.
* Students who are accepted into the ELIS program may be offered a spot at a school outside of their catchment area.
*** Please note that transportation is the responsibility of the family.***

Consent and Release Form

Publishing and sharing student information and work*

I give Permission for my child/self to be photographed and/or have personal information shared, as described in our Student Media Release Form

I do not give Permission for my child/self to be photographed and/or have personal information shared, as described in our Student Media Release Form

Student Acceptable Use of Technology Form

As the parent or guardian of this student, I have read the Responsible Use Policy. I understand that technology is provided for educational purposes in keeping with the academic goals of Prairie South School Division, and that student use for any other purpose is inappropriate. I recognize it is impossible for the school to restrict access to all controversial materials, and I will not hold the school responsible for materials acquired on the school network. I understand that children’s computer activities at home should be supervised as they can affect the academic environment at school.*

As the parent or guardian of this student, I have read the Responsible Use Policy. I understand that technology is provided for educational purposes in keeping with the academic goals of Prairie South School Division, and that student use for any other purpose is inappropriate. I recognize it is impossible for the school to restrict access to all controversial materials, and I will not hold the school responsible for materials acquired on the school network. I understand that children’s computer activities at home should be supervised as they can affect the academic environment at school.

I/ We agree to Prairie South Student Responsible Use Policy, as described in the Student Responsible Use Policy

Consent to Exchange Information

I hereby consent to the release of information to the Prekindergarten Selection Committee for any agency, I have identified in this application that pertains to my child's eligibility for enrolment in the Prekindergarten program at Prairie South School Division

I understand that the information contained in this application will be held in confidence by the Prekindergarten Selection Committee.*

I agree by checking this box, I, the applicant, acknowledge that this will act as a signature on my behalf.

Declaration:

I, the undersigned, hereby represent that I have the legal authority to apply for this child. I declare the information that I provided on this form is complete and accurate. I will notify the school of any changes to the information on this form.

Name of person submitting application:*

First Name Last Name

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

MM slash DD slash YYYY

agree_consent*

I Agree by checking this box I the applicant acknowledge that this will act as a signature on my behalf.*

Signature of Parent (Type full name as signature) :*

Date of Application*

MM slash DD slash YYYY

Name

This field is for validation purposes and should be left unchanged.

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Contact Us

Prairie South School Division
1075 9th Ave N.W
Moose Jaw, SK S6H 1V7

Phone:
1-306-694-1200
Fax:
1-306-694-4955
Toll Free:
1-877-434-1200

Find us on:

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Prairie South School Division

ELIS Application Form

ELIS Application Form

If your child was born in 2020 or 2021, please submit your application for PreK for the 2024-2025 school year. Students are eligible to begin PreK once they turn 3. If your child was born in 2019, please register for Kindergarten for the 2024-2025 school year.

Application:

PSS Catchment Area Map

Background Information:

Land Location:

Citizenship:

Parent(s)/Guardian(s) Contact Information

Land Location:

Land Location:

Daycare/Babysitter Contact:

Emergency Contact Information:

Voluntary Indigenous Self Declaration:

The Canadian Constitution recognizes three distinct groups of Indigenous people.

Please check the box that best identifies your child: *

Siblings:

First Sibling Information:

Second Sibling Information:

Third Sibling Information:

Fourth Sibling Information:

Health History:

Early Learning Behaviours and Experiences:

Speech

Please outline the strengths and needs of your child in the following areas:

Service Providing Agencies:

Consent and Release Form

Student Acceptable Use of Technology Form

Consent to Exchange Information

Declaration:

If your child was born in 2020 or 2021, please submit your application for PreK for the 2024-2025 school year. Students are eligible to begin PreK once they turn 3.
If your child was born in 2019, please register for Kindergarten for the 2024-2025 school year.