Dear Family or Referral:

Transcription

1 Dear Family or Referral: APPLICATION for: South Carolina School for the Deaf and the Blind 355 Cedar Springs Road, Spartanburg SC Phone: (864) Toll Free: (888) Fax: (864) Thank you for your interest in the educational programs at the South Carolina School for the Deaf and the Blind (SCSDB). We are proud of our programs and welcome the opportunity to participate in your child s education. To be enrolled at our school, students must meet our criteria for admission upon initial acceptance and for continued enrollment at the school. You can help expedite this process by collecting the information below and sending it to us with your application. To begin, please send the complete application packet, along with the following: q A copy of your child s registered birth certificate or other document to verify a birth record. q A copy of your child s custody papers if there is a legal directive, or guardianship papers if the child is not living with the parents q Proof of SC residency (Two of the following documents are required): o Current electric and/or gas bill displaying service address and a billing date within past 30 days (can bring 2 utility bills) o Closing statement or current mortgage statement for primary residence showing property address (not mailing address) o Current signed lease agreement with name and phone of landlord o Most recent state or federal income tax return o Current paid tax receipt on real estate owned by parent/legal guardian o Property tax form requesting homestead exemption o Current statement from DSS or other governmental agency which proves residency of the parent/legal guardian o Current paycheck stub with address of residence q Please note, we must receive the Physician Summary form (page 9 of the application) completed by your student s physician prior to processing the application Upon receipt of your signed Authorization for Release of Information form, the following medical/service agency records will be requested, as appropriate: q A vision or eye exam report from an optometrist or ophthalmologist (This exam must be done within the past 3 years if the child is over age 6, or within the past 12 months if the child is under age 6.) q A hearing exam report from an audiologist (same time frame as above) q Any other important medical information necessary for the team s review. q Information about any social services the child has received And finally, we will request the following educational records: q A copy of the most recent Individualized Education Program (IEP), IEP Progress Reports, Evaluation/Reevaluation Documentation and Reports, Eligibility Determination Form, Functional Behavior Assessments, Behavior Intervention Plans, Extended School Year information (ESY), Special Education Placement Forms, Discipline Records, and any Transition Plans q Copies of school transcripts and grades q Copies of standardized test scores If your child meets admission criteria to SCSDB, evidence of current immunizations and results of TB test will be required prior to enrollment. 1

2 APPLICATION for: South Carolina School for the Deaf and the Blind 355 Cedar Springs Road, Spartanburg SC Phone: (864) Toll Free: (888) Fax: (864) Social Security Number: Student: First Middle Last Date of Birth: Place of Birth qmale qfemale Cultural Background: q American Indian or Alaska Native q Asian q Black or African-American q Native Hawaiian or Pacific Islander q White/Caucasian Is your child Hispanic/Latino? q YES qno Student s Primary Language: q ASL q English q Spanish q Other Primary Language at Home: q ASL q English q Spanish q Other Does your child use assistive communication devices? q YES qno Does your child have special transportation needs? q Wheelchair q Car Seat q Medication q Harness qother Custodial Parent/Guardian: Name: Relationship Occupation First Last Address: Street City State Zip Code Phone: Home Work Cell Address: County Date of Birth Parent/Guardian: Name: Relationship Occupation First Last Address: Street City State Zip Code Phone: Home Work Cell Address: County Date of Birth Siblings/Other Individuals in the Home: Name: Age: Name: Age: Name: Age: 2 Name: Age:

3 Home School: District #: County: Address Street City State Zip Code Contact Person: Phone Previous Schools Attended: City Grade(s): City Grade(s): City Grade(s): Primary Disability: q Deaf/Hard of Hearing q Blind/Visually Impaired q Other Secondary Disabilities: PLEASE COMPLETE RELATED SECTION: Deaf/Hard of Hearing: Hearing Information Cause of Deafness/Hearing Impairment: Age of onset Age that deafness/hearing impairment was confirmed Age fitted with hearing aid (if applicable) For students with Cochlear Implants, please complete the following: Brand of cochlear implant: Date/Year of surgery: Age of current processor: Is the cochlear implant still under warranty for repairs? If so, when does it expire? Name/Location of implant center: Phone number of center/audiologist (if known): Date of most recent mapping: How often does your child wear his/her cochlear implant? qdaily qoccasionally qmostly at home qrarely qnever How much benefit from the cochlear implant does your child receive? q Able to understand spoken language. q Able to understand some spoken language but still needs sign support. q Not able to understand spoken language but uses for awareness of speech/environmental sounds/music. q Does not benefit. 3

4 What kind of communication does your child use at home? q ASL q Other sign system (i.e. Signed English) q Simultaneous communication (talking and signing) q Spoken English q Other spoken language (i.e. Spanish) Does your child also use a hearing aid? q YES q NO Blindness/Vision Impairment: Cause of Blindness/Vision Impairment: Age of onset: Age that blindness/vision impairment was confirmed: Age prescribed contacts or glasses: Are glasses/contacts uses consistently? q YES q NO Age and nature of eye surgery: Does your child receive orientation and/or mobility services? q YES q NO Reason applying for admission to the South Carolina School for the Deaf and the Blind: How did you learn about SCSDB? Student resides with: q Mother q Father q Both q Other Do you expect your child to be a: q residential student, OR q day student. The SC School for the Deaf and the Blind does not discriminate on the basis of race, color, religion, national origin, age, sex, or disability in admission to, treatment in, or employment in its programs and activities. Inquiries regarding nondiscrimination policies should be made to the Human Resources Manager, 355 Cedar Springs Rd, Spartanburg, SC 29302, (864) PLEASE PRINT NAME: RELATION TO STUDENT SIGNATURE DATE 4

5 STUDENT INFORMATION SHEET for: South Carolina School for the Deaf and the Blind 355 Cedar Springs Road, Spartanburg SC Phone: (864) Toll Free: (888) Fax: (864) PLEASE PRINT Student s Name: Health Information 1. Were there any complications during pregnancy or at birth? q Yes q No If yes, please explain: 2. Was your child premature? q Yes q No Please list birth weight: 3. Were developmental milestones on target? (i. e., sitting alone, walking, feeding self) q Yes q No If no, please explain: 4. Did your child receive Early Intervention services? q Yes q No If yes, please list: 5. Does your child have difficulty going to bed on time? q Yes q No 6. Does your child wet the bed? q Yes q No 7. Does your child have food allergies? q Yes q No If yes, please list: 8. Does your child have choking tendencies when eating? q Yes q No 9. What is your child s overall general health? q Good q Average q Poor 10. Are there any past or current health concerns or surgeries? q Yes q No If yes, please explain: 11. Does your child take prescription medication? q Yes q No If yes, please list: 12. Is your child allergic to any medications? q Yes q No 5 If yes, please list:

6 13. Does your child have any physical restrictions? q Yes q No If yes, please explain: 14. Does your child have any vision problems (including use of contacts or glasses)? q Yes q No If yes, please explain: 15. Does your child use hearing aids? q Yes q No 16. Does your child have a cochlear implant? q Yes q No 17. Has your child had any serious illness, accidents, head injuries, high fever, etc.? q Yes q No If yes, please explain: Communication Information 18. What is your child s primary means of communication? 19. What is your primary means of communication with your child? Behavior Information 20. Does your child follow the rules at home? q Yes q No If no, please explain: 21. Does your child get along with his/her siblings? q Yes q No 22. Has there been any serious recent traumatic experience that has affected the behavior of your child? (i.e., death, divorce, abuse) q Yes q No If yes, please explain: 23. Has your child received counseling or mental health services? q Yes q No If yes, please list agency and contact number: 24. Has your child been referred to the Department of Juvenile Justice? q Yes q No If yes, please explain: 25. Has your child ever been away from home for a period of time? q Yes q No 26. Does your child enjoy school? q Yes q No 6

7 27. Does your child get along well with his/her classmates? q Yes q No 28. Does your child have any learning problems? q Yes q No If yes, please explain: 29. Does your child follow the rules at school? q Yes q No If no, please explain: 30. Has your child ever been suspended or expelled from school? q Yes q No If yes, please explain: 31. Has your child ever received any physical or occupational therapy? q Yes q No If yes, please explain: 32. What type of discipline works best with your child? 33. What does your child enjoy doing in his/her free time? 34. Name two of your child s personality strengths: and 35. Name two of your child s personality weaknesses: and Behavioral Checklist: Please check all that apply to your child: Does not sleep well Does not eat well Is depressed Walks while sleeping Has temper tantrums daily Is overactive Controls temper Has many mood changes Hurts self Hurts others Hurts animals Has strong fears Follows directions well Is overly dependent for age Engages in unusual sexual activity Has nightmares Uses profanity Steals Is frequently off-task. Other behaviors that concern you: 7

8 Physician Information: List all doctors, specialists, and service agencies from the last two years: Family Physician: Name Phone Vision/Hearing Doctors: Name Phone Name Phone Specialists and/or Service Agencies: (family, medical, therapeutic services) Agency Phone Agency Phone Agency Phone Agency Phone Information used or disclosed pursuant to this authorization may be subject to re-disclosure by Current School District and School Greenville County Schools (GCS). I understand that at any time I may revoke this authorization, except to the extent that GCS has already taken action based upon released information. I also understand that in order to terminate this authorization I must submit a statement in writing to GCS and/or to any office/agency covered under the release, saying that authorization has been revoked. In the absence of a written statement from me AUTHORIZATION revoking this authorization, for RELEASE it will OF expire INFORMATION upon the date that the student Student Name: Date of Birth: South Carolina School for the Deaf and the Blind is requesting permission to exchange information with the individuals/agencies listed above for the purpose of admission determination and educational planning. If your child is admitted to the School, you understand and agree that the School may contact the listed individuals/agencies to discuss your child as the School deems necessary in the best interests of your child. Requested Information: Special Education Due Process Records Medical Records (Select all that apply) Health Hearing Motor Speech Vision Other: I hereby authorize you to release the requested information pertaining to services that were provided to my child. Signature of parent/guardian: Date: 8 I am the parent guardian.

9 PHYSICIAN SUMMARY FOR: South Carolina School for the Deaf and the Blind 355 Cedar Springs Road, Spartanburg SC Phone: (864) Toll Free: (888) Fax: (864) Please have YOUR CHILD S PHYSICIAN complete the following medical information for South Carolina School for the Deaf and Blind s school physician. Student Name Date of Birth: Sex: Student s medical history and current needs: Medical history of family if relevant to student s medical history: Allergies to Medications: Allergies to Foods/Other things: Special Diet: Activity Restrictions: Current medications: Special medical treatments the child needs: Signature: Date: Physician s Printed Name: 9