WTD Application

Application for Enrollment (WTD)

The What To Do About Your Brain-Injured Child course will teach you how to evaluate your child and design an effective program of stimulation and opportunity to do at home.

Step 1 of 15

Please specify the dates and location of course you wish to attend(Required)

Who is enrolling in the course?(Required)

With whom should we communicate? (Primary Contact)(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent 1 Name:(Required)

First Last

Parent 1 Occupation:(Required)

Parent 1 Age:(Required)

English is a native language for you:(Required)

Please, write your email:

Telephone number:

Have you read the book, "What To Do About Your Brain-Injured Child," by Glenn Doman?(Required)

We urge you to read this book, in its entirety, before attending the course.

Parent 2 Name:

First Last

Parent 2 Age:

Parent 2 Occupation:

English is a native language for you:

Please, write your email:

Telephone number:

Have you read the book, "What To Do About Your Brain-Injured Child," by Glenn Doman?(Required)

We urge you to read this book, in its entirety, before attending the course.

Primary Phone:(Required)

Primary Email:(Required)

How did you hear about us?(Required)

What families do you know on The Institutes program?

How would you describe your level of English:(Required)

Parents come from many nations to attend the course and naturally English may not be the primary language for these parents. It is very important that we know how well you speak and understand English so we can advise you about your need for translation.

If English is not native to you, please specify what language is.

Consent

I understand

If you are not completely fluent in English, we will not be able to confirm your place in the course until we have arranged translation for you. We will contact you about these arrangements.

Information About Your Child:

Name:

First Last

Date of Birth:

MM slash DD slash YYYY

Sex:

Please describe your child's degree of visual (seeing) competence (ex: Do they track objects, read, have glasses, look at you):

Describe in detail what you feel your child can or cannot see:

Please describe your child's degree of auditory (hearing) competence (ex: Do they startle with noises, sensitive to sounds, look at you when you call their name, etc.):

Describe in detail what you feel your child can or cannot hear:

Please describe your child's degree of tactile (feeling) competence (ex: tell the difference between hot and cold, do they feel sharp objects, won't eat different textures, sensitive to different feelings like sandpaper, velvet, silk):

Please describe in detail what you feel your child can and cannot feel:

Please describe your child's degree of mobility competence (ex: Does your child move arms and legs freely, do they crawl, creep, walk, run, jump, kick, use both hands together, etc):

Describe in detail how your child can or cannot move:

Please describe your child's degree of language competence (Does your child use any words, read, understand what you are saying, etc):

Describe in detail how your child can or cannot communicate:

Please describe your child's degree of manual competence (ex: hold a spoon, use a pencil, play with blocks, throw a ball, twist off cap, etc):

Describe what your child can and cannot do:

Does your child have seizures? If yes, which anti-seizure medications is your child taking?

Please list medicines and drugs your child has taken and is taking now:

General state of health. Please describe any and ALL hospitalizations (for what reason and how long), been on rounds of antibiotics, if they are sick often, have regular respiratory infections, allergies, etc.):

Please list all previous diagnoses:

Do any siblings have neurological problems?

Is your child currently attending school?

Please provide a summary of pregnancy, labor and birth:

Please provide a summary of your child's development from birth to now, such as when they hit certain milestones, concerns you have currently with their development, etc:

Is there any information that you want us to have that we have not asked about? Please feel free to add any additional information that you believe may be helpful:

Max. file size: 128 MB.

Please attach a recent photo of your child:(Required)

Max. file size: 128 MB.

Consent(Required)

I agree to the privacy policy.

I understand my information will never be rented/leased/sold. I consent to being kept up to date about the Institutes via email. I understand I can opt-out out of these emails via the link in the email footer. I consent to be contacted via the phone with the number I have provided above.

Number

Application for Enrollment (WTD)

Information About Your Child:

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