Career Independent Living and Learning Studies (C. I. L. L. S) Application for Admission



Download 58.37 Kb.
Sana09.09.2017
Hajmi58.37 Kb.


East Stroudsburg Universitylogoprep

Career Independent Living and Learning Studies (C.I.L.L.S) Application for Admission



Student information





Last Name




First




M.I.

Date




Mailing Address




Apartment/Unit #




City




State




ZIP




Home Phone




E-mail Address




Cell Phone




*Social Security No.




Birth Date




Gender

Female 

Male 

* The student’s SSN and date of birth are confidential and protected under federal law from being disclosed to unauthorized parties. Your SSN will not be used as your student ID number. Your SSN will be safeguarded by the University and will not be displayed on official records or be made available to others.

Most effective mode of communication or language.


Racial/ethnic information (optional):
Alaskan Native or American Indian  African American/Black  Asian  Hispanic/Latino (a)
 Native Hawaiian or Other Pacific Islander  White, not of Hispanic/Latino (a) origin  Other
Describe any concerns you may have that would impact the applicant’s ability to be successful in this Program (i.e., behavioral, emotional or educational).

Describe your preparations in assisting this student in making the transition to college life.







Please indicate if the student ever lived away from his/her primary caregiver (s) for:
 Camp  School  Vacation  Other

If yes, where did the student live and for how long?


Were there any adjustment issues?  Yes  No If so, please explain

Has the student used public transportation on their own to get to school or work?  Yes  No


Does the student use a cell phone independently?  Yes  No
Does the student have a driver’s license?  Yes  No
Does the student have his/her own vehicle?  Yes  No

FAMILY /GUARDIAN INFORMATION


Student lives with:  Both Parents  Mother  Father  Guardian  Other _____________________


Mother/guardian





Last Name




First




M.I.

Date




Mailing Address




Apartment/Unit #




City




State




ZIP




Employer/

Occupation






Work Phone




E-mail Address




Cell Phone





Father/guardian





Last Name




First




M.I.

Date




Mailing Address




Apartment/Unit #




City




State




ZIP




Employer/

Occupation






Work Phone




E-mail Address




Cell Phone




Siblings:


How many siblings does the applicant have?

Please indicate the age, gender, and any other relevant information.




Age

Gender

Any Other Relevant Information



























EDUCATION HISTORY OF STUDENT:

(Include primary, secondary and any post-secondary experiences)


Name of School

Location

Description of Program—public, private, transition, etc

Years

Attended


Completed

Y or N






























































If applicable, list your student’s general education courses during the last two years of high school.

If applicable, list the subjects that your student participated in a resource class during the last two years of high school.
If applicable, describe any self-contained classroom experiences that your student had during the last two years of high school.

Does your student have an IEP?  No  Yes (If so a copy of the IEP must be submitted with the application materials)


Does your student have a 504 Plan?  No  Yes (If so, a copy must be submitted with the application materials)
Was a high school diploma awarded or, if the student has not graduated, is a high school diploma expected?

 Yes  No


Was a certificate of attendance awarded or, if the student has not graduated, is a certificate expected?

 Yes  No



SUPPORT SERVICES PROVIDED BY SCHOOL OR PRIVATE THERAPIST*
Please provide information on the Support Services your student received in school or from a source other than school.

Type of Service

Duration of Service

Description of your student’s accommodations:

Occupational Therapy







Physical Therapy







Speech and Language








Assistive Technology







Other







*C.I.L.L.S. Program fees and tuition do not include the cost of these services if continued.
Please indicate, in your opinion, the most effective learning strategies for your student:
 Auditory  Reading  Visual Aid
 Memorization  Repetition  Experiential Learning

Describe how your student compensates for learning and cognitive disabilities when managing a task.



EXTRACURRICULAR/VOLUNTEER ACTIVITIES:


Organization

Description of Activity

Dates

Hours/Week


















































EMPLOYMENT HISTORY:


Name of Employer

Position & Job Responsibilities

Hours/

Week

Dates of

Employment

Reason for Leaving

Paid or

Volunteer









































































Was listed a job coach on site for any of the employment experiences?  No  Yes


If so, please list which positions had a job coach on site:
Describe how the job was obtained, i.e., by school, family, provider, other?

What accommodations were provided at work?



MEDICAL/DISABILITY HISTORY

Name of Physician:

Phone

Address

City

State

Zip Code




Date of last medical exam:

Has the student had problems with incontinence?  Yes  No If so, does the student use any of the following mobility aids?
 Prosthesis (specify: )  Braces  Crutches  Cane  Manual Wheelchair  Motorized wheelchair/cart
Does the student require any canine assistance?  No  Yes, please explain:




Has the student ever had a seizure?  No  Yes, please explain and provide dates/treatment:





Please provide information on all medical conditions or diagnosis, other than common childhood illnesses.




Medical Condition:

Date of Diagnosis:

Description of the medical condition:

Does this impact the daily living of the student Y or N
















































Please list any medications the student is prescribed.





Please indicate the student’s ability on each task below. Place a checkmark in the appropriate box.




Medication Skills

Completely

Independent

Minimal

Assistance

Moderate Assistance

Complete Assistance

Not Applicable

Organizing medications daily or weekly
















Understands what medication to take at correct/times daily
















Understands what medication to take in response to symptoms















Does the student understand why he/she is taking the medication?  Yes  No


Please explain:



Please provide information about any hospitalizations the student has had.





Dates of Hospitalization

Reason for Hospitalization


















Has the student had any incidents of aggressive physical or verbal behavior?  No  Yes, please list the date, and nature of the situation(s) (Please attaché any Functional Behavioral Assessments or Support Plans that may have been completed for the student):






Does the student have a history of legal violation, arrest or probation?  No  Yes, please list the dates and nature of the situation (s):








RECOMMENDATIONS:
Three recommendation forms should be completed by non-relatives who have known the applicant for at least one year. One reference must be from an educator. Other references should be an educator, supervisor, employer, family friend, or a service provider. Letters of recommendation should be sent directly to the C.I.L.L.S. Program by the person completing the reference. The recommendation forms must be received by March 1, in order to be considered for the fall of the upcoming academic year.
Reference Information:


  1. ____________________________________________________ Date:_____________________

Name

_______________________________________________________________________________

Address (city, state, zip, country)


  1. ____________________________________________________ Date:_____________________

Name

_______________________________________________________________________________

Address (city, state, zip, country)


  1. ____________________________________________________ Date:_____________________

Name
_______________________________________________________________________________

Address (city, state, zip, country)


My signature below indicates that all information contained in this application is factually correct and complete. I understand that the misrepresentation or omission of application information is sufficient grounds for canceling my admission or registration. I understand that I will not receive undergraduate credit for any courses taken within the C.I.L.L.S. Program.
Student Signature: _______________________________________________________ Date:__________________________
My signature below indicates that all information contained in this application is factually correct and complete. I understand that the misrepresentation or omission of application information is sufficient grounds for canceling my admission or registration. I understand that I will not receive undergraduate credit for any courses taken within the C.I.L.L.S. Program.
Parent or Guardian Signature: ______________________________________________ Date:___________________________
East Stroudsburg University prohibits discrimination in employment, educational programs, and activities on the basis of race, national origin, color, creed, religion, sex age, disability, veteran status, sexual orientation, gender identity, or associational preference. The University also affirms its commitment to providing equal opportunities and equal access to University facilities. For additional information, contact the Office Ethnicity and Diversity.

Download 58.37 Kb.

Do'stlaringiz bilan baham:




Ma'lumotlar bazasi mualliflik huquqi bilan himoyalangan ©hozir.org 2020
ma'muriyatiga murojaat qiling

    Bosh sahifa
davlat universiteti
ta’lim vazirligi
O’zbekiston respublikasi
maxsus ta’lim
zbekiston respublikasi
o’rta maxsus
davlat pedagogika
axborot texnologiyalari
nomidagi toshkent
pedagogika instituti
texnologiyalari universiteti
navoiy nomidagi
samarqand davlat
guruh talabasi
ta’limi vazirligi
nomidagi samarqand
toshkent axborot
toshkent davlat
haqida tushuncha
Darsning maqsadi
xorazmiy nomidagi
Toshkent davlat
vazirligi toshkent
tashkil etish
Alisher navoiy
Ўзбекистон республикаси
rivojlantirish vazirligi
matematika fakulteti
pedagogika universiteti
таълим вазирлиги
sinflar uchun
Nizomiy nomidagi
tibbiyot akademiyasi
maxsus ta'lim
ta'lim vazirligi
махсус таълим
bilan ishlash
o’rta ta’lim
fanlar fakulteti
Referat mavzu
Navoiy davlat
umumiy o’rta
haqida umumiy
Buxoro davlat
fanining predmeti
fizika matematika
universiteti fizika
malakasini oshirish
kommunikatsiyalarini rivojlantirish
davlat sharqshunoslik
jizzax davlat