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Career and Community Studies                                             Vonnie Michali
Kent State University                                                    Director of Career Dev.
Center for Innovation in Transition & Employment                         Phone: 330.672.0729
150 Terrace Drive                                                        E-mail: yhale@kent.edu
218 White Hall
Kent, Ohio 44240

                        Application for Admission Fall 2011
                         STUDENT DEMOGRAPHIC INFORMATION

Last Name:                   First Name:                    MI:         Phone:

Address:                                           Highs School Graduation Date:

City:                        State:                Zip:                 Date of Birth:

Email address:                                                          Cell phone:
Name of High School:                           Type of Diploma:

Social Security #                              Social ________ Formal ________ None _______




                         FAMILY DEMOGRAPHIC INFORMATION
Parent:
Last Name:                    First Name:                         MI:           Phone:

Address:                               City:                               State:          Zip:

Occupation/ Employer:                                             Work Phone:

Email address:                                                    Cell phone:


Parent:
Last Name:                    First Name:                         MI:           Phone:

Address:                               City:                               State:          Zip:

Occupation/ Employer:                                             Work Phone:

Email address:                                                    Cell phone:

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                                                                                       Page |2


                            MEDICAL/DISABILITY HISTORY
                                             Part A
Please list disability diagnoses and give a brief description of applicant’s medical history.
Detail any conditions that may impact your ability to function within the classroom or on
campus, including severe allergies. Are there any restrictions on physical activities, and in
what way? Additionally, discuss when you were first diagnosed and any subsequent issues.
If you need more space, please attach an additional page.




Please list current medications and indicate what the medications are taken for. Attach a
separate sheet if you need more space.




NOTE: Applicant must be independent in administering his/her medications if necessary during
KSCC hours.
Do you have any problems with incontinence?                            yes      no
Is the applicant independent with basic hygiene?                       yes      no
Is applicant independent in mobility (walk or use wheelchair)?         yes      no
Do you require an attendant or aide?                                   yes      no
If so, an aide must be provided by the school or family.
NOTE: If necessary, student/family will need to arrange for personal assistance services in order
to attend the CCS.


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                                                                                            Page |3

                              Based upon the MAPS: Magill Action Planning System


                           WHAT IS THE FAMILY’S HISTORY?
                                           Question 1
Please discuss pertinent family background that lead you to believe the Career and Community
Studies Program would be a proper placement for you. Additionally, please give detailed
information regarding the kind of help you may need to accomplish daily activities. Have you
accessed any types of outside support services? If you need more space, please attach an
additional page.




Do you have a case open with (check all that apply):
BVR _____ MR/DD_______SSI______Mental Health______ Other ____________________



                                TELL US ABOUT YOURSELF
                                             Question 2
Please describe yourself in detail. What descriptive words come to mind? Please provide any
additional information deemed important beyond what has been stated in Part A regarding your
interests, strengths, preferences, and needs. Please list hobbies/interests. If you need more space,
please attach an additional page.




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                                                                                        Page |4




HONORS & AWARDS RECEIVED: Academic or non academic awards. Please indicate
dates and conferring institution, group, agency and organization. Use a separate piece of paper if
you need more space.

     NAME OR TYPE                         CONFERRING                           DATES OF
          OF                          INSTITUTION/AGENCY                        AWARD
     HONOR/AWARD                         ORGANIZATION




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D. MEMBERSHIP AND COMMUNITY INVOLVEMENTS: List participation in
    any Local, State or National organizations. (Ex: Church, volunteer work, community sports).

 Activity                             Date of Participation               Amount of Time
                                                                            devoted




 Activity                             Date of Participation               Amount of Time
                                                                            devoted




                                               Question 3
   Do you currently receive private therapeutic services, such as behavioral therapy occupational
   therapy, psychiatry, and/or speech therapy? If so, please indicate which services and attach a
   copy of the current report as indicated on the front of the application. Are there any triggers or
   certain things that may quickly upset you? If you need more space, please attach an additional
   page.




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                          WHAT ARE THIS PERSON’S DREAMS?
                                          Question 4
What are your long term goals upon completion of the CCS?
How do you envision an ideal life? What types of employment are you interested in? What type
of living arrangements? If you need more space, please attach an additional page.




                               WHAT ARE THE CONCERNS?
                                          Question 5
What are your or your family’s concerns about the future? What do you want to gain from
participating in the CCS? If you need more space, please attach an additional page.




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                                 EMPLOYMENT HISTORY
                                             Part B
Please complete the following if you have any prior work/vocational experience. Begin with
current or most recent experience. Please provide a resume (optional but not necessary).

Name of Business/Company            Paid or Unpaid?   Reason for        Amount of time at
                                                       Leaving               Job


Please list job responsibilities:




List any support services provided:




Name of Business/Company            Paid or Unpaid?   Reason for        Amount of time at
                                                       Leaving               Job




Please list job responsibilities:




List any support services provided:



Name of Business/Company            Paid or Unpaid?   Reason for        Amount of time at
                                                       Leaving               Job


Please list job responsibilities:




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                                  SUPPORT INVENTORY
                                            Part C
  Please rate your ability in the following areas by marking an X in the appropriate box:

Independent Living Skills                             Needs        Needs        Needs
                                                    complete       much          little     Completely
                                                    assistance   assistance   assistance   independent
Finding way around new environment
Following a schedule
Managing personal belongings
Preparing simple meals
Ordering from a restaurant
Finding items in a store
Taking public transportation
Washes own clothes

Social Skills and Communication                       Needs        Needs      Needs
                                                    complete       much        little       Completely
                                                    assistance   assistance assistance     independent
Communicating needs appropriately
Asking for help
Dealing with conflict
Distinguishing between friends & strangers
Interacting appropriately with peers
Respecting authority figures
Using cell phone
Verbalizing and/or writing personal information
(name, address, phone, etc.)

Academic Skills                                       Needs        Needs        Needs
                                                    complete       much          little     Completely
                                                    assistance   assistance   assistance   independent
Identifying value of coins/bills
Counting change/bills
Using a calculator
Managing a checking account
Staying within a budget
Using a computer for word processing
Navigating the Internet
Using email
Following verbal directions
Following written directions




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Reading and writing skills: (check highest level)

Writing:
  no functional writing    writes name                   writes/copies all letters
  writes complete words     writes short sentences      correctly uses punctuation
  drafts, revises, edits
  uses Assistive Technology If yes, please identify: _______________________________

Reading:
  no functional reading       identifies letters    recognizes familiar words/names
  applies reading strategies (sentence structure, meaning, phonetic clues)
  reads chapter books          reads books silently

Listening comprehension:
   retells a simple story
   can retell the beginning, middle, and end of stories
   able to retell settings, characters, problems, major events and solutions of stories

Computer skills: Can you use a computer to:
Do homework assignments
Communicate with others
      Email
      Facebook
      Twitter
      Others __________________________________
For entertainment
      Games
      Music
      Graphic designs
      Other ___________________________________




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                                  PARENT EXPECTATIONS
                                              Part D
As a parent, please list what your expectations are for the Career and Community Studies
program? What do you hope your student will learn? Why do you want your student to
participate in this program? Are you willing to encourage your student to explore new
opportunities and to learn new skills? Are you willing to participate in parent classes once a
month to identify what new skills your student has learned and to learn how you can help
him/her practice those skills at home and in the community? If you need more space, please
attach a separate sheet.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________________________________



                              ADDITIONAL INFORMATION
                                           Part E
Please use this page to provide us with any other information that you may want to share:




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                             Career and Community Studies
                                              Part F

                         EMERGENCY MEDICAL INFORMATION


School: ______________________________                 Student Name: _______________________

Grade: _______________________________                 Address: ____________________________

Date of Birth:__________________________                        ____________________________

COMPLETE EITHER PART I OR II

Part I – To Grant Consent

Mother’s Name: ____________________________ Daytime Phone: ______________________

Father’s Name:_____________________________ Daytime Phone: ______________________

Guardian’s Name :___________________________Daytime Phone: ______________________

Local alternate persons to be notified in case neither parent can be reached:

Name: ____________________________________ Daytime Phone: ______________________

Name: ____________________________________ Daytime Phone: ______________________

Name: ____________________________________ Daytime Phone: ______________________

Doctor to be called :____________________________               Phone: _____________________

Doctor to be called :____________________________               Phone: _____________________

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent
for (1) the administration of any treatment deemed necessary by above-named doctor or, in the
event the designated practitioner is not available, by other licensed physician or dentist; and (2)
the transfer of the child to any hospital reasonable accessible.

Preferred Local Hospital: __________________________Emergency Room Phone;__________

This authorization does not cover major medical surgery unless the medical opinions of two
other licensed physicians or dentists, concurring in the necessity for surgery, are obtained prior to
the performance of each surgery.




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Facts concerning the child’s medical history, including allergies, medications being taken, and
any physical impairments to which a physician should be alerted: (write on back if necessary)




Signature of Parent/Guardian _________________________________Date: ________________

PART II – REFUSAL TO CONSENT
I DO NOT give my consent for emergency medical treatment of my child. In the event of illness
or injury requiring emergency treatment, I wish the school authorities to take no action or to:




Signature of Parent/Guardian ________________________________Date: _________________

Address: ______________________________________________________________________




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                            Career and Community Studies
                                            Part G

Driver Authorization

Please complete this form to let us know who is authorized to pick you up from CCS. Students
should be dropped off under the building (White Hall); Monday through Thursday, before 9 a.m.
This is where they must be picked up every class day at 3 p.m. unless otherwise specified.


Student: ______________________________________________________________________


#1 Driver Name: _______________________________________________________________


Relationship to student: ______________________Number: ____________________________



#2 Driver Name:_______________________________________________________________


Relationship to student: ______________________Number: ____________________________



#3 Driver Name: _______________________________________________________________


Relationship to student: ______________________Number: ____________________________



If there are any special circumstances to be aware of please inform the Project Director, Thomas
Hoza, at 330-672-0723.



Signature: ________________________________________________Date: ________________




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                                            Part J


                                   Student Consent Form:

                A Transition and Postsecondary Program for Students with
                     Intellectual Disabilities at Kent State University

        We want to do research to see if the college campus is a good place for you to learn
how to get a job and to live on your own under a grant from the Office of Postsecondary
Education at the U.S. Department of Education.. Taking part in this project is entirely up
to you, and no one will hold it against you if you decide not to do it. If you do take part,
you may stop at any time. You will get a copy of this consent form.
        We would like you to take part in this research by sharing your experiences with us
and by letting us assess your academic, career, and life skills several times a year. These
assessments will include grades, standardized evaluations, and interviews that will occur
while you are enrolled in Kent State University classes, work experiences, social activities,
and independent living experiences.
        Participation in this program does not pose any risks greater than what might be
experienced by a typical college student. Medical Assistance or emergency medical
treatment by the University Health Center is provided to currently registered students.
Please be advised that for all others, “911” will be called for physical injuries occurring on
the Kent State University main campus. You or your medical insurance will be billed for
this service. No other medical treatment or financial compensation for injury from
participation in this project is available.
        Information about you will be maintained under the confidentiality requirements of
your IEP team and federal regulations. The results of this study will be used in the writing
of writing of articles to educational journals and in presentations at local, state, and
national conferences. In sharing information, your name and any identifying information
will be removed to ensure your privacy.
        If you want to know more about this research project, please call me at 330-672-
0723. The project has been approved by Kent State University. If you have questions
about Kent State University's rules for research, please call Dr. John West, Vice President
of Research, Division of Research and Graduate Studies (Tel. 330.672.2704).



Sincerely,

Tom Hoza, Project Director

B. CONSENT STATEMENT(S)
1.     I agree to take part in this project. I know what I will have to do and that I can stop
at any time.

______________________________________________________________________________
Signature                                                           Date


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                                    Parent Consent Form:

                A Transition and Postsecondary Program for Students with
                     Intellectual Disabilities at Kent State University

        We want to do research to see if the college campus is a good place for students with
intellectual disabilities to learn how to get a job and to live on their own. We are doing this
with a grant from the Office of Postsecondary Education at the U.S. Department of
Education.. Taking part in this project is entirely up to you and your child, and no one will
hold it against you if you decide not to do it. If you and your child do take part, you may
stop at any time. You will get a copy of this consent form.
        We would like your child to take part in this research by sharing his or her
experiences with us and by letting us assess academic, career, and life skills several times a
year. These assessments will include grades, standardized evaluations, and interviews that
will occur while your child is enrolled in Kent State University classes, work experiences,
social activities, and independent living experiences.
        Participation in this program does not pose any risks greater than what might be
experienced by a typical college student. Medical Assistance or emergency medical
treatment by the University Health Center is provided to currently registered students.
Please be advised that for all others, “911” will be called for physical injuries occurring on
the Kent State University main campus. You or your child’s medical insurance will be
billed for this service. No other medical treatment or financial compensation for injury
from participation in this project is available.
        Information about your child will be maintained under the confidentiality
requirements of your IEP team and according to federal regulations. The results of this
study will be used in the writing of articles to educational journals and in presentations at
local, state, and national conferences. In sharing information, your child’s name and any
identifying information will be removed to ensure your privacy.
        If you want to know more about this research project, please call me at 330-672-
0723. The project has been approved by Kent State University. If you have questions
about Kent State University's rules for research, please call Dr. John West, Vice President
of Research, Division of Research and Graduate Studies (Tel. 330.672.2704).

Sincerely,

Tom Hoza, Project Director

B. CONSENT STATEMENT(S) : I agree to take part in this project. I know what I will
have to do and that I can stop at any time.

______________________________________________________________________________
Signature                                                           Date




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                       AUDIO / VIDEOTAPE / PHOTOGRAPH CONSENT FORM

                          Developing College Campuses as Transition Settings
                        for Students with Developmental Disabilities Aged 18-21.

Dear (Student, Parent, Guardian)

We want to use videotapes and audiotapes of your experience in our college program for
students with intellectual disabilities. These video and audiotapes will be taken by you and of
you to document your experiences here. These videos will be used to share your experiences
with educators, families, advocates, and policy-makers in state and national presentations.


       I agree to ______ audio taping, ______ video taping, and ______ being photographed (check all that
       apply)

       at anytime during the course of a program activity or function from June 26t, 2011 to September 30,
       2016.

       _______________________________________________________________________________
       Signature                                          Date


       I have been told that I have the right to hear and see the audio tapes / video tapes / photographs before
       they are used. I have decided that I:

       ______Want to hear / see the tapes / photographs    ______Do not want to hear / see the tapes /
       photographs


       Dr. Robert Flexer, Tom Hoza and other researchers approved by Kent State University may / may not
       (Circle one) use the tapes / photographs made of me. The original tapes / photographs or copies may
       be used for:

       _____This research project _____Teacher education _____Presentation at professional meetings


       ____________________________________________________________________________________

       (Student Signature)                                                           Date

       Address: ____________________________________________________________________________

       Phone: _____________________________________________________________________________




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                                     Recruitment Form:

                A Transition and Postsecondary Program for Students with
                     Intellectual Disabilities at Kent State University

Greetings: (Student Name)
        We want to do research to see if the college campus is a good place for you to learn
how to get a job and to live on your own under a grant from the Office of Postsecondary
Education at the U.S. Department of Education.. Taking part in this project is entirely up
to you, and no one will hold it against you if you decide not to do it. If you do take part,
you may stop at any time. You will get a copy of this consent form.
        We would like you to take part in this research by sharing your experiences with us
and by letting us assess your academic, career, and life skills several times a year. These
assessments will include grades, standardized evaluations, and interviews that will occur
while you are enrolled in Kent State University classes, work experiences, social activities,
and independent living experiences.
        Participation in this program does not pose any risks greater than what might be
experienced by a typical college student. Medical Assistance or emergency medical
treatment by the University Health Center is provided to currently registered students.
Please be advised that for all others, “911” will be called for physical injuries occurring on
the Kent State University main campus. You or your medical insurance will be billed for
this service. No other medical treatment or financial compensation for injury from
participation in this project is available.
        Information about you will be maintained under the confidentiality requirements of
your IEP team and federal regulations. The results of this study will be used in the writing
of writing of articles to educational journals and in presentations at local, state, and
national conferences. In sharing information, your name and any identifying information
will be removed to ensure your privacy.
        If you want to know more about this research project, please call me at 330-672-
0723. The project has been approved by Kent State University. If you have questions
about Kent State University's rules for research, please call Dr. John West, Vice President
of Research, Division of Research and Graduate Studies (Tel. 330.672.2704).

Sincerely,

Tom Hoza, Project Director

B. CONSENT STATEMENT(S) : I agree to take part in this project. I know what I will
have to do and that I can stop at any time.

______________________________________________________________________________
Signature                                                           Date




                                                                          Revised March 2011
       P a g e | 18




Revised March 2011

				
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