Tennessee State University Department of Speech Pathology & Audiology Language, Articulation, Fluency (L.A.F.) Summer L.A.

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1 Tennessee State University Department of Speech Pathology & Audiology Language, Articulation, Fluency (L.A.F.) Summer L.A.F Camp 2018 Speech Pathology and Audiology will provide intensive therapeutic intervention focusing on Language, Articulation and Fluency for qualified applicants, ages There is no cost. Persons interested should scroll down to download the application and submit it along with any prior diagnostic assessment reports, IEPs and other pertinent data, to the following address: L.A.F. Camp Department of Speech Pathology and Audiology th Ave. North, Suite N200 Nashville, TN Applications must be postmarked on or before April 26, Scheduled Diagnostics: June 12 th -13th Full Camp Dates: June 18 th through July 12 th Time: Monday through Thursday, 9:00 am 3:00 pm Articulation Camp Treatment of speech sounds Fluency Camp Treatment and maintenance stuttering therapy Language Camp Treatment and maintenance of receptive and expressive language Contact Persons: Shennel Williams (615) & Danielle Watson TSU (B)-7c Tennessee State University: A Tennessee Board of regents Institution. TSU is an equal opportunity, affirmative action institution committed to educating a nonracially identifiable student body. In accordance with the American with Disabilities Act, persons who need assistance with this material may contact the Department of Speech Pathology & Audiology at (615) or (615) Tennessee State University is an AA/EEO employer

2 TENNESSEE STATE UNIVERSITY Language, Articulation and Fluency Camp CAMP INTAKE FORM FILE # CAMP PARTICIPANT S FULL NAME: FATHER S NAME: MOTHER S NAME: ADDRESS: TELEPHONE: Home Work Cell DATE OF BIRTH: AGE: GENDER _M / F (Circle One) PRIOR SPEECH SERVICES RECEIVED (When) (Where) Is the camp participant a current client in the T.S.U. Speech Clinic? Yes_/_No (Circle One) Is the child a returning L.A.F. Camp participant? _Yes_/_No (Circle One) PROBLEM DESCRIPTION: REFERRED BY: DATE: FOOD ALLERGIES AND RESTRICTIONS: The following people have permission to sign my child in and out of camp: 1. Name Phone number: 2. Name Phone number: 3. Name Phone number: Parent/Guardian Signature: Date: ********TO BE FILLED OUT BY CLINICAL STAFF********* DIAGNOSTIC SCHEDULED FOR: Date Time: AM/PM Page 2 of 11

3 TENNESSEE STATE UNIVERSITY DEPARTMENT OF SPEECH PATHOLOGY AND AUDIOLOGY th Avenue North, Suite A Box 131 Nashville, TN PERSONAL HISTORY-CHILD Note: Please complete this form and return to the above address. Include Department of Speech Pathology and Audiology Date: I. GENERAL INFORMATION Child s Full Name Current Age Birthdate Sex: M( ) F( ) Address: Street City State Zip Code Phone#: Mother s full name: Age Education completed: Residence: Daytime Phone # Father s full name: Age Education completed: Residence: Daytime Phone # List all persons living in the home: Name Age Relationship Family Physician Pediatrician I believe my child has difficulty with: speech (articulation) language voice Page 3 of 11

4 fluency hearing other Describe the problem in detail (Use back of sheet if needed): What do you think caused the problem? What has been done to correct it? How does the child seem to feel about his/her problem? Does any other family member have a speech or hearing problem? (If yes, state nature of problem and relationship to child) II. EARLY HISTORY Health of mother during pregnancy Diseases, accidents, drugs, x-ray treatment of mother during pregnancy Exposure to any infectious diseases during pregnancy Which pregnancy was this child? Full term? Length of labor? Was delivery normal? Child s weight and condition at birth Describe any birth problems Was child s development normal for sitting, standing, walking, etc.? Describe any health or feeding problems during early childhood III. LANGUAGE DEVELOPMENT (List ages carefully. This is very important.) When did child begin to babble or coo? When did child speak first words? Sentences How does the child make his wants known? Page 4 of 11

5 Was there anything different about the way the child made sounds, noises, words, etc., during the first two years? Explain. (Preferred to point or gesture; started talking and then stopped, etc.) When was the problem first noticed? By whom? Has the child s speech changed recently? What does the child do when his speech is corrected? Does the child repeat your questions instead of answering them? IV. HEARING (Complete if you think your child has a hearing problem) What makes you think your child has a hearing problem? How old was the child when you realized there was a hearing problem? Does he pick or pull his/her ears? Does your child wear hearing aids? Left Ear Right Ear Both Ears V. HEALTH HISTORY (Give age and severity of following illnesses your child has had). Illness Age Describe Illness Measles Mumps Chicken Pox Pneumonia Allergies Tonsillitis Ear Infections Fainting Seizures Diabetes High Fever Visual Asthma Frequent Colds Thyroid Trouble Paralysis Heart condition Other What operations and/or serious accidents has the child had? (include dates) What medication, if any, does the child receive? Is the child clumsy? Explain SCHOOL Page 5 of 11

6 Current School Address Grade Teacher What is the child s attitude toward school? Describe any school difficulties (reading, writing, etc.) Has the child ever had an intelligence test? Explain VI. EMOTIONAL ADJUSTMENT AND PERSONAL CHARACTERISTICS How would you describe the child s personality? How does the child respond to people? Is the child hard to manage? Does the child sleep and eat well? How is the child punished? Has the child ever experienced a severe shock or fright? If so, explain *Notes: 1. It is very likely that your child s session/s will be observed by students enrolled in Speech Pathology or Audiology courses. 2. It is our policy to terminate clients who are absent from therapy for 3 consecutive sessions without prior notification from the client to the Clinical Coordinator or Supervisor. Page 6 of 11

7 CONSENT FORM: TESTING/THERAPY/RESEARCH Patient s Name: 1. I do do not give my permission for me/my child to receive speech/language/hearing screening(s) for the Tennessee State University Speech and Language Clinic. 2. I do do not give my permission for me/my child to receive speech/language/hearing evaluation(s) from tbe Tennessee State University Speech and Language Clinic. 3. I do do not give my permission for me/my child to receive speech/language/hearing therapy from the Tennessee State University Speech and Language Clinic. 4. I do do not give my permission for the Tennessee State University Speech and Lanugage Clinic to use my/my child s clinical information anonymously for research purposes only. 5. I do do not give my permission for me/my child to be observed by Tennessee State University s students. 6. I understand that a complete Diagnostic Evaluation must be completed by Tennessee State University Speech and Language Clinic before therapy service can be initiated. 7. I understand that Speech-Language therapy services will be cancelled in the event of missed appointments without proper notification. Signature (if under 18 years of age, parent/guardian) Date Page 7 of 11

8 Tennessee State University Language, Articulation and Fluency Camp Client/Family Responsibilities The Tennessee State University (TSU) L.A.F. Camp provides intensive articulation, fluency and language therapy for children. The children receive direct instruction from student clinicians who are supervised by ASHA certified speech language pathologists. 1. The TSU Speech/Language Camp will be held Monday through Thursday beginning and ending from am until. Clients/Children who are enrolled in the TSU Speech/Language Camp must attend sessions on time ( am) in the morning and be picked up from Camp on-time ( ) at the end of the day. 2. Clients/Participants in the LAF Camp must be able to use the bathroom independently. 3. If a parent(s)/legal guardian(s)/caregiver(s) has/have to cancel a client s/child s session due to illness or other conflicts, he/she/they should contact his/her/their client s/child s primary supervisor or the clinic secretary at before 8:30 am on the day of the session. 4. A parent(s)/legal guardian(s)/caregiver(s) has/have the right to request a meeting with his/her/their child s clinical supervisor(s) or clinician(s). A 48 hour advance notice is requested. 5. A parent(s)/legal guardian(s)/caregiver(s) has/have the right to review his/her/their child s clinical chart. A 48 hour advance request is requested. 6. If a client/child misses two (2) consecutive sessions, he/she may be dismissed from camp. 7. The TSU Department of Speech Pathology & Audiology reserves the right to dismiss, suspend or refuse services to clients/children who present either health, physical and/or behavioral concerns to themselves, other camp participants and/ or to TSU staff. 8. A parent(s)/legal guardian(s)/caregiver(s) has/have the right to observe his/her/their child, but not to disrupt the treatment process. 9. A parent(s)/legal guardian(s)/caregiver(s) must be in attendance the first day of camp to sign all consent and release forms and must sign all applicable forms. 10. A parent(s)/legal guardian(s)/caregiver(s) must sign his/her/their child in to the TSU Speech Camp each day and sign the child out of camp at the end of each day. Identification may be required. No minor child shall be left or dropped off or picked up without being signed in/out of the TSU Speech Camp. No minor child shall be allowed to enter or exit the TSU Speech/Language Camp without parent/guardian/caregiver supervision or signed permission. Page 8 of 11

9 11. TSU Department of Speech Pathology & Audiology reserves the right to dismiss, suspend or refuse services to clients/children who presents either health, physical and/or behavioral concerns, to themselves, other camp participants and/or TSU staff. 12. TSU s Speech and Language Clinic, TSU, the Tennessee Board or Regents and the State of Tennessee assume no responsibility for personal injury or for conduct by any person, whether a program participant or not, for personal property loss, including, but not limited to, loss of clothing, jackets, shoes, eyeglasses, or back packs, purses, wallets, calculators, cameras, cell phones, computers, ipads, PDA s, electronic readers, books, jewelry, money, and video or audio equipment 13. The speech/language services in the TSU Speech/Language Camp are not guaranteed to be offered without interruption for the duration of the 2012 Summer Camp. Print Childs Name Signature of Parent/Guardian Date Signature (If under 18 years, Parent/Guardian) Date Student Clinician Date Page 9 of 11

10 Department of Speech Pathology Summer Language, Articulation and Fluency (L.A.F.) Camp Release and Wavier I, the parent/legal guardian of have voluntarily decided to allow to participate in the Summer Speech/Language camp program located at Tennessee State University (TSU) in Nashville, Tennessee, with the full knowledge of the responsibilities associated with my child s participation in the Summer Speech/Language camp and its related activities during the summer of. I voluntarily grant permission for my child to participate in Summer Speech/Language camp program activities at TSU. I hereby release TSU and its employees from any and all liability related to my child s participation in any and all program activities, traveling to and from campus or on campus, eating, and all other activities, conduct, occurrences or events in which my child may be involved. I am competent to make this decision for my minor child, I agree to assume and expressly accept any and all risks related to my child s participation in this program. My child is not suffering from any medical condition, impairment, or disease that would prevent the safe participation in any of the activities involved in the L.A.F. Camp or activity in which my child will be involved or that would prevent my child s participation in program or event activities. I have not been advised by a physician or any other health care provider to limit my child s activities. I assume responsibility for my child s participation in the activities and any injuries while participating in activities or travel to and from the activity. TSU s Speech and Language Clinic, TSU, the Tennessee Board of Regents and the State of Tennessee assume no responsibility for personal injury or conduct by any person, whether a program participant or not, for personal property loss, including, but not limited to, loss of clothing, jackets, shoes, eyeglasses, or back packs, luggage, purses, wallets, calculators, cameras, cell phones, computers, ipads, game boys, digital planners or PDA's, electronic readers, books, jewelry, money, and video or audio equipment. I agree to not hold TSU liable for any loss or injury that occurs while my child is on TSU s campus, traveling to or from campus, or participating in the program, program events whether oncampus or off-campus. I release and forever discharge the State of Tennessee, Tennessee Board of Regents, TSU, and their respective employees, agents, and representatives (the releasees ) from any and all liability for injuries or damages resulting from my child s participation in program or my child s use of equipment. I also release the releasees from any responsibility or liability for injury or damage to my child or injury or damage my child may cause to others, including that caused by the negligent act(s) or omission(s) of releasees or in any way arising out of or connected with my child s participation in any event or related activity, or the use of any equipment, whether owned by myself or others. This release will also prevent my family from suing releasees and binds my spouse, if I have one, my estate, siblings, parents, heirs, and assigns. I acknowledge that TSU is not responsible for providing medical treatment or medical coverage if my child is injured or if my child injures someone else, and that TSU will be in no way responsible for any injury, loss or untoward event that occurs. TSU Department of Speech Pathology & Audiology reserves the right to dismiss, suspend or refuse services to clients/children who presents either health, physical and/or behavioral concerns, to themselves, other camp participants and/or TSU staff. Page 10 of 11

11 Print name of Participant Print name of Parent/Legal Guardian If Less than 18 Years of Age Signature of Parent/Legal Guardian Date Page 11 of 11