Pallotti High School

The Learning Center at St. Vincent Pallotti High School strives to accommodate the needs of students who have been diagnosed with a mild to moderate learning disability. If you are interested in applying to The Learning Center, please fill out the following application by December 15, 2010. You may also:

Download our Teacher Recommendation form to present to a teacher
Apply to the Learning Center separately by clicking here or downloading the Learning Center Application Form

Please note that an interview with the Director of the Learning Center, Mrs. Diane Kime, will be required of all applicants. Qualified applicants will be called to schedule their interview for the month of January.

Applicant Information
*Last Name:	*First Name: MI:
*Email:	*Gender:
*Address:
*City:	*State:
*Zip:
*Home Phone:	*Date of Birth:
Ethnicity:	Citizenship:
*Current Grade:	*Grade Applying For:

*Current School:	*Date Entered:
*Current School Address:
*City:	*State:
*Zip:

Diagnosis Information
Diagnosed Disability:
Date of first diagnosis:
Dates of most recent testings:	(Must be within last three years):

Name of tests administered:
Name of doctor(s)/ examiner(s):
Qualifications of doctor(s)/ examiner(s):
List current accommodations used in school and on standardized tests:

Assessment Scores and Dates
Psychological Assessment: WISC IV WJIII Testing Date:
Psychological Assessment Standard Scores: Full Scale IQ: Verbal IQ: Performance IQ: Perceptual Reasoning: Verbal Reasoning:
Academic Assessment Testing Date:
Academic Assessment Scores: Broad Reading: Broad Math: Broad Written Language: Broad Knowledge/Academic Knowledge: Total Achievement:
Is your child diagnosed with ADD/ADHD? Yes No
Does your child take medication? Yes No
If so, name and dosage of medication:
Types of accommodations seeking (check all that apply):
Extended Time Reduced Written Work Write answers on test/quiz (not scantrons) Seated in front row Reader Scribe (someone to write word for word what student dictates)	Extra Breaks Large Print Use of a calculator Copies of notes Use of a word processor or grammar & spelling don't count Formulas for math & science assessments provided

* I understand that if accepted, I will keep my child's testing current (never more than 3 years old) or I may be dismissed from the program.