Gortnamóna N.S.

Blueball, Tullamore, Co. Offaly.

Phone No. 057 9354960 E mail: gortnamonans@gmail.com

Pre-Admission Form for Special Class for children with ASD

Childs Information:

First Name: ___________________ Last Name: _________________

Date of Birth: __________________ PPSN: ________________________

Please note: All applicants must be 4 years of age on or before 30th June in
year of enrolment.

Gender (Please tick): Female Male

Nationally: ____________________________

Previous school/pre-school/early intervention attended, if applicable:

____________________________________________________________

Parent/guardian Information

Name 1: ___________________________

Name 2: ____________________________

Address: _____________________________

______________________________

______________________________

Phone Numbers: __________________________________________

Email: __________________________________________________
 I understand that:
 The receipt of a pre-admission form does not guarantee that my child will
be offered a place
 It is my responsibility to inform the school of any change of contact
details or any other relevant circumstances
 If I have not replied to confirmed offer of a place for my child by date
specified, I will have forfeited my child’s place

Documentation

Please ensure that the following is supplied with the application as otherwise it
will not be processed:

An original Birth Certificate

A diagnosis from a psychiatrist, psychologist, or a member of a Multi –

Disciplinary team that has assessed and classified the child as having autism or

autistic spectrum disorder according to DSM-V or ICD 10 criteria and a

recommendation for a placement in a special class within a mainstream school.

Any other relevant reports – speech and language therapy / occupational

therapy and psychological reports.

Signed: _______________________ Date:_______________________

Please send completed application form to:

Gortnamona National School,

Blueball,
Tullamore,
Co. Offaly.

For Gortnamona NS use only:

Date Form Received: _________________

Age: _________________ Original Birth Cert:

Area: _________________ Relevant report/ Recommendation

Date letter of offer sent: ___________

Offer accepted: Offer declined: