COVERING LETTER by monkey6

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COVERING LETTER

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									COVERING LETTER

Dear Parent/Guardian,

APPLICATION FOR ATTENDING ELJADA INSTITUTE

Thank you for your Enquiry

We take care of Intellectually Disabled Adults from the age of years until they are
deceased. Our aim is to have a home that is renowned for its loving environment where
every inmate is strongly supported to develop and discover their potential, irrespective of
race, sex, belief, language, economic status or sexual orientation.

The applications have to be deliberated by the Professional Committee who meets once
every term.

It is of utmost importance that the enclosed application form has been completed in full.
Incomplete Forms will be returned, wasting the time for the applicant to be accepted.
Your Request must include the following:

      The fully completed application form with the personal details of the applicant;
      Medical report, completed by a medical practitioner who has insight on the
       circumstanced;
      A short life history till present of the applicant (the more detail the better);
      A full length photo of the applicant (recently taken)

The Board has the right to expel any applicant whose application form was not completed
honestly. Candidates have a probationary period of three months at Eljada Institute. The
final decision will be made after this period. Please contact the manager if you require
any help.

Yours sincerely,

Prof. M.C. Potgieter
Manager
                        APPLICATION FOR INCLUSION
              [N.B. A full length photo of the applicant must be attached]

Identity number of applicant:


Surname: …………………………….                         First Name(s): …………………………….

Nickname: …………………………...                       ID Number: ………………………………

Date of Birth: ………………………..                    Place of Birth: ……………………………

First Language: ……………………...                   Religious Denomination: ………………...


Contact details of Parent/Guardian:

Address:
…………………………………………..
…………………………………………..
…………………………………………..
Tel: ……………………………………...
Cell: ……………………………………..




Schools, Centres or institutes attended by applicant - specify the years:
……………………………………………………………………………………………...
Date last attended: ……………………....            Highest grade achieved: ………………….
Are you a member of a medical aid? ……………………………………...........................
If Yes: Name of medical aid: ……………………………………………………………...
Name of Main Member: …………………………………………………………………...
Membership No. …………………………………………………………………………..


Family details:

Name of father: …………………………..                 Date of birth: ……………………………..
Occupation: ………………………………                     Income: …………………………………..


                                             Date of birth: …………………………….
Name of mother: …………………………
Occupation: ………………………………                     Income: ………………………………….
Maiden name: ………………………….…

Are your parents involved? Yes/No?: …………………………………………………….
If Yes, to what extent are they involved?: ………………………………………………...


Children:
                                                   Gender: ……………              Age: …………….
Name of Child 1: …………………………
Name of Child 2: ………………………… Gender: …………… Age: …………….
Name of Child 3: ………………………… Gender: …………… Age: …………….
Name of Child 4: ………………………… Gender: …………… Age: …………….
Other Residents (Example: Grand Parents / lodgers):
……………………………………………………………………………………………..


Family Relationships towards the applicant (Comprehension, Insight, Acceptance).
Explain in one short sentence:

Father: ……………………………………………………………………………………..
Mother: …………………………………………………………………………………….
Brothers: …………………………………………………………………………………...
Sisters: …………………………………..............................................................................

Why are you applying to the institute?:
………………………………………………………………………………………………
………………………………………………………………………………………………

What discipline does the applicant have at this stage?:
………………………………………………………………………………………………
………………………………………………………………………………………………


General information regarding the applicant - description needed:

Injections/Inoculations: ……………………………………………………………………
………………………………………………………………………………………………

Operations: ………………………………………………………………………………...
………………………………………………………………………………………………

Childhood illnesses: ……………………………………………………………………….
………………………………………………………………………………………………


Other illnesses: …………………………………………………………………………….
………………………………………………………………………………………………

Allergies: …………………………………………………………………………………..
………………………………………………………………………………………………

Seizures or morbidity present in applicant: ……………………………………………….
……………………………………………………………………………………………...

Regular medication used by applicant: ……………………………………………………
………………………………………………………………………………………………


Prenatal History:

Duration of pregnancy: ……………………………………………………………………
Did any abnormalities occur during pregnancy?: …………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………


Development History:

At what age did the applicant achieve the following milestones?:

Sit: ……………………………………….                        Crawl: …………………………………….
Walk: …………………………………….                        Attend School: ……………………………


Emotional state and behaviour:

Excited: ………………………………….                      Passive: …………………………………..
Moody: ………………………………….                        Loving: …………………………………...


Behavior: [Describe in one sentence]

Can the applicant carry out instructions?: …………………………………………………
………………………………………………………………………………………………
Is the applicant disciplined?: ………………………………………………………………
………………………………………………………………………………………………
Is he / she easily influenced?: ……………………………………………………………..
………………………………………………………………………………………………
Does he/she make friends easily?: ………………………………………………………...
………………………………………………………………………………………………
Describe his/her relationship with the opposite sex?: ……………………………………..
………………………………………………………………………………………………
How dependent is the applicant when it comes to the following:

Continence (day): ………………………………………………………………………….
Continence (night): ………………………………………………………………………..
Eat with spoon: ……………………………………………………………………………
Eat with knife and fork: …………………………………………………………………..
Getting dressed and undressed: …………………………………………………………..
Bath: ………………………………………………………………………………………
Washing hair: ……………………………………………………………………………..
Brushing teeth: ……………………………………………………………………………
Making his/her bed: ………………………………………………………………………
Writing: …………………………………………………………………………………..
Reading: ………………………………………………………………………………….


Interests of the applicant:
………………………………………………………………………………………………
………………………………………………………………………………………………

What skills does the applicant have:
………………………………………………………………………………………………
………………………………………………………………………………………………

Strange behavior and habits:
………………………………………………………………………………………………
………………………………………………………………………………………………

General:
………………………………………………………………………………………………
………………………………………………………………………………………………

I, the undersigned, hereby declare that the above information is true.
Signature:

Father: ………………….............

Witness: ………………………...

Mother: …………………………

Witness: ………………………...

Guardian (If applicable): ………………………

Date of application: ……………………………
                                  MEDICAL REPORT:
                        [For completion by your medical practitioner]

Name of applicant: ………………………….

Address: ……………………………………..
         ……………………………………..
         ……………………………………..


Original factors regarding the disability:

………………………………………………………………………………………………
………………………………………………………………………………………………

Epilepsy(if present):

Type of seizure: ……………………………………………………………………………
Frequency per month: ……………………………………………………………………..
Current Medication (Complete description): ……………………………………………...
………………………………………………………………………………………………


Allergies (if present): ……………………………………………………………………..
………………………………………………………………………………………………

Physical Condition:

Weight(kg): ………………………………                       Height(m): ………………………………..
Blood Group: …………………………….                      Urine Test: ……………………………….


Please inform us about the following:

Sight: ………………………………………………………………………………………
Hearing: ……………………………………………………………………………………
Skin: ……………………………………………………………………………………….
Chest: ……………………………………………………………………………………...
Heart: ………………………………………………………………………………………
Speech: …………………………………………………………………………………….
Any other physical deficiencies: …………………………………………………………..
Birth Restrictions: …………………………………………………………………………
Morale:

Stress condition: …………………………………………………………………………...
………………………………………………………………………………………………
Prescribed medication: …………………………………………………………………….
………………………………………………………………………………………………
Psychotic condition: ……………………………………………………………………….
………………………………………………………………………………………………


History of illnesses or deficiencies in the family:
………………………………………………………………………………………………
………………………………………………………………………………………………

General:
………………………………………………………………………………………………
………………………………………………………………………………………………

Name and address of your Medical Practitioner :
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………

								
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