Foirm Iarratas
do Rang Speisalta Uathachas
Application form for Special Class for Pupils with ASD
Ainm an linbh / Child’s full Name as on Birth Cert :…………………………………
Seoladh / Home Address:…………………………………………………Eircode…………..
Dáte Breithe / Date of Birth:……………Dáta tosnú ar scoil /Date of Entry to School: Sept 2022
Rang / Class child will attend: Rang Speisialta Uathachas / Special Needs Class for Autism
Áit a rugadh an linbh / Place of Birth:……………………....
Áit sa chlann / Place in Family:………….. P.P.S. N. …………………….
Aon Paiste eile as chlann sa scoil / cén rang / Names and classes of other children in family attending this school…………………………..
………………………………………………………………………………
Creideamh / Religion:……………………..
Tá an paiste ina chonaí le / Child lives with: both parents mother father guardian
Ainm an Athar / Father’s Name:………………………... Telephone No…………………..
Ainm an Mathair / Mother’s Name:……………………….. Telephone No………………..
An raibh an linbh ar aon scoil ribh seo. / Did the child attend school previously (nursery, naíonra, early intervention class, primary school )
Ainm an Príomhoide / Principal’s / Organiser’s Name:………………………………
Ainm agus Seoladh an scoil / Name and Address of Setting…………………………
…………………………………………………………………………………
Tuairiscí á lorg:
Caithfidh gach dalta atá ag lorg áit sa rang Speisialta tuairiscí a comhlionann criteir an uathachais agus a deireann go bhfuil áit in Rang Speisialta i Scoil Meansruthach riachtanach agus oiruíach don pháiste.
Each child applying for a space in Special Class for Pupils with ASD must have diagnosis of Autism, DSM or ICD 10 criteria approved by a professional individual approved by the Dept of Education.. This report must be current and include a recommendation that a placement in a special class in mainstream school is both necessary and suitable for the child.
Please attach this report to this application.
Please also attach all other relevant supporting documents, other reports from professionals, schools etc.
Síniú Tuiste / Caomhaoir / Signature of Parent or Guardian ………………………..
Data / date…………………