DEEP Inclusion Application

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The Derry Early Education Program is an inclusive preschool program in which typically developing peers attend along side students who are identified with an educational disability. By completing this application, I understand that my child is being considered for admittance into the inclusion program. Children are expected to have age appropriate speech and language skills, social skills, model appropriate behavior and be toilet trained prior to the start of school. If you have concerns regarding your child's development, please contact Kelly Fitch @ 603-845-1202. Please complete the following application for the Derry Early Education Program 2024-2025 school year. Once submitted, you will be contacted by office staff regarding placement, deposit and registration information.

Email *

Child's Full Name (first, middle, last) *

Date of Birth *

YYYY

Address *

Parent/Guardian #1 Name *

Parent/Guardian #2 Name

Parent/Guardian # 1 Contact Information (please include phone number and email address) *

Parent/Guardian #2 Contact Information (please include phone number and email address)

Does your child have any medical diagnoses? *

Yes

Required

If your child has a medical diagnosis, please explain.

If your child has allergies, please explain.

What language(s) are spoken in the home? *

Do you have any concerns regarding your child's hearing? *

Describe your child's favorite activities. *

How does your child communicate with others? *

Does not use speech or gestures to communicate

Uses single words

Uses sentences, but is not understood by others

Uses sentences that can be understood by others

How does your child understand speech? *

Does not understand what is said to him/her

Understands some of what is said to them

Understands familiar statements

Understands everything said to him/her

Please give an example of your child's typical speech. *

Describe how your child interacts with other children. *

Has your child ever had any preschool or daycare experience? If so, please elaborate. *

Please describe how your child plays with toys (e.g.pretends with objects, mouths objects, length of play, plays alone, plays with a variety of toys, imitates, etc.) *

DEVELOPMENTAL HISTORY: Please check all that apply. Please note these skills are not required, but a way for us to learn more about your child and their learning. *

Looks at books

Identifies colors

Identifies shapes

Separates easily from parent or caregiver

Expresses/Understands emotions

Follows rules and routines in a group setting

Takes turns with others

Runs without falling

Ascends/Descends stairs (may hold railing)

Climbs

Uses scissors

Uses a pencil or crayon

Puts puzzles together

Stacks blocks

Is toilet trained

Has basic safety awareness (holds a hand, responds to no and stop, etc.)

Required

Do you have any concerns regarding your child's behavior?

Please tell us why you and your child would like to participate in the Derry Early Education Inclusion Program? *

If you have a preference for the morning or afternoon session, please indicate below. (although we do our best to accommodate requests, session preference is not guaranteed) *

AM 8:30am-11:00am

PM 12:20pm-2:50pm

No preference

Required

Is there anything else you would like to share to help us to get to know your child better?

A copy of your responses will be emailed to the address you provided.

Submit

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