NCSE Form 3 Assistive Technology Grant • Parent & Pupil Intake

DEPT. OF EDUCATION • NCSE SECURE DOSSIER INTAKE

🌲 Assistive Technology Grant Intake

Circular 0010-2013 (DES Assistive Tech Scheme) • €0 Parent Co-Pay Allocation

Please enter or verify your child's details below to finalize the grant allocation.

1. Pupil & Parent Details

Step 1 of 4

Pupil / Child Name

Pupil Age Years

Parent / Guardian Name

Contact Email

Mobile Phone

Eircode

Home Address

2. Clinical Assessment & Diagnosis

Step 2 of 4

Primary SEN Diagnosis / Communication Needs

Speech & Language Therapist (SLT)

Occupational Therapist (OT)

3. School Placement & SENO

Step 3 of 4

School / Educational Institution

School Roll No.

SENO District (Special Ed Organiser)

4. Parent Digital Signature

Step 4 of 4

I confirm that the details provided are accurate for the NCSE Form 3 Assistive Technology Grant under Circular 0010-2013 (DES Assistive Tech Scheme) (€0 Co-Pay).

Draw Signature Below (Finger or Stylus)

Touch / Pen Active

🌲 Assistive Technology Grant Intake

🎉 Statutory Grant Dossier Submitted!