CHILD AND FAMILY DEVELOPMENT 590L
CHILDREN WITH SPECIAL NEEDS
Spring 2014
Course Information
Instructor:
Don Myers, Ph.D.
Office:
EBA 401
Telephone:
619 460-8221
Email:
donmyers@drdonmyers.com
Office Hours: Tue 2:00-3:45
Prerequisites
CFD 270 or PSY 230; CFD 353A, 353B, 353C; and completion of 12 upper division CFD units with a
grade of C (2.0) or better. These upper division units do not include the CFD 378 labs.
Course Description
For this lab, students are assigned to work with a child with special needs in his/her home; or to work
with special-needs children/young adults in a school, agency, childcare, or group home setting.
Students will meet with their assigned child/children/young adult once a week for at least 2 hours
(12 weeks in total and at least 24 hours). Each visit must be at least 2 hours. Visits cannot be broken
into smaller timeframes. The child’s parents, teacher, or supervisor, along with the student, will decide
what will be accomplished at each meeting. For students working with children in their homes,
activities such as playing indoors, playing outdoors, assisting with in-home therapy, and helping with
homework are all acceptable activities. It is also possible to participate in parent support group
meetings, doctor appointments, school activities, IEP meetings, therapy, etc. If the student and parents
are comfortable, children may be taken on outings away from the home. For students working in a
group setting, activities involve play, therapy, caregiving, instruction, etc.
Negative TB Clearance
Students must show proof of a current negative TB clearance (January 2013 or more recent). Students
will not receive their lab placements until a copy of their negative TB card is submitted to Don Myers.
These copies will be kept in the students’ files. Do not submit the original TB card, only copies will be
accepted. If you cannot take the TB skin test, a letter from your doctor stating you do not have TB will
be fine. The letter, however, must be dated January 2013 or more recent. If you are placed at a school
or agency, you will also submit a copy of your negative TB clearance to your supervisor on your first
day.
Course Objective
For students working with children in their homes, your objective is to establish a relationship with
your assigned child and his/her family. For students working in group settings, your objective is to
work with the children/young adults to enhance their developmental outcomes, and if working with the
same child/young adult/children on a weekly basis, to establish a relationship with him/her/them.
Contacting Families or Centers
On the first day of class, you must submit the Student Contact Information Form. Fill out the first
three lines of this form with your contact information. You will also submit prerequisites (highlight
relevant courses on your Degree Audit Report), the signed CFD Reflective Learning Portfolio
Agreement (if applicable), proof of a negative TB screen, and complete the Lab Request Form to
indicate preferences for lab placement (child, school, agency, group home). Many of the lab
placements are described in this syllabus. Effort will be made to meet each student’s request, but it is
not always possible. Supporting the children/young adults and our community sites is our priority, so
you may not get your choice if you are not a good fit for that child/young adult or site. Lab
assignments will not be made until prerequisites, Reflective Learning Portfolio Agreement (if
applicable), and negative TB screen are submitted. By Thursday January 30, you will receive your
placement via email (check email frequently). During the second week of school, Dr. Myers will give
you a letter of introduction written by the student from last semester who worked with your assigned
child/young adult/teacher/school. This letter should give you a better understanding of your lab
placement. Once you receive your assignment, familiarize yourself with the child’s diagnosis or your
agency/school (do an Internet search) and then contact the child’s parents, teacher, or supervisor right
away to arrange the first meeting. Again, DO NOT WAIT, email or phone the parent, teacher, or
supervisor right away. Try to meet as soon as possible, as journals and logs are due weekly beginning
on Thursday February 13. On your first visit, spend some time with your assigned child’s
parent/teacher/supervisor and arrange a day and time that you will meet each and every week. Do not
stay in this class if you are too busy to meet weekly at the same day and time. If you are too busy
to meet on a regular basis, you will have to drop the class and take it when you have more time.
The children and families are very excited to meet you, so try to relax and enjoy your first meeting. Do
not take your own children or the children you care for on these visits, no exceptions.
Professionalism and Ethical Behavior
Dress modestly, yet comfortably (no short skirts/shorts/shirts, no low-cut shirts, etc.). If you work at a
school or agency, it is up to you to learn their rules and follow their dress code. Please know that some
families, schools, agencies do not allow facial piercings and/or tattoos. Let me know if this applies to
you and I will not assign you to those placements. Show professionalism and be respectful and
responsible. You are expected to be punctual and reliable. Always show up as scheduled (anticipate
traffic problems). If an appointment must be missed, let the family/supervisor know well in advance.
The children look forward to the visits and are very disappointed when you do not show up as
expected. Grades for the lab class are based partly on professionalism. Points will be deducted for
irresponsibility and lack of professionalism, as well as not visiting on a regular basis. This is a
semester-long experience. You are responsible for visiting weekly and spreading your hours evenly
over the entire semester. You must finish the semester with at least 12 visits and at least 24 hours.
Plan to spend at least two hours each time you visit.
Ethical behavior is expected at all times. Students will fail CFD 590 for unethical behavior. This
includes forging signatures, writing about visits that did not occur, writing about activities that did not
occur, falsifying documents, etc. Students will also be referred for disciplinary procedures that may
result in dismissal from the university.
Weekly Reflective Journals and Visit Logs
Journals of your weekly visits are due every Thursday, beginning on February 13 (see class calendar
included in syllabus for due dates). These will be submitted to Don Myers by the end of class each
Thursday. Journals should be brief, about half a page in length, and typed. Handwritten journals are
not accepted. Along with the journal, the completed and signed “Weekly Visit Log” should also be
turned in (available on Blackboard and included to this syllabus). Please staple the journal to the visit
log (no paperclips or folded edges). It is your responsibility to take the “Weekly Visit Log” to each
meeting and to have it completed in full. Written notes from the parents, teachers, or supervisors
stating that you completed your visit or handwritten logs are not acceptable. Only the “Weekly Visit
Log” will earn the student full credit. If you are unable to visit the child, school, or center, you must
still submit a journal indicating why you were not able to visit. You are responsible for making up the
missed visit at a later date in which you will turn in a makeup “Weekly Visit Log” and journal. These
journals and logs will not be returned. It is your responsibility to keep track of your visits and
hours (keep a photocopy of each journal and log you submit). Points will be deducted for late
journal/logs, incomplete logs, missing logs/journals, no staple, etc.
Grading
You will receive one letter grade for CFD 590. One-quarter of the grade (24 points) will reflect your
work with your assigned child/young adult. Students who turn in weekly journals/logs that are
completed correctly and are on time, have a total of at least 24 hours and at least 12 visits, have worked
consistently throughout the entire semester, show professionalism, submit the two well-written letters
(on time), and receive a good evaluation from the parent/teacher/supervisor, should earn all 24 points
for this lab class.
Assignment
Twelve weekly journals and logs
Thank-you letter to parent/supervisor/teacher
Introduction letter to new student
Points
18 points (1.5 points each)
3 points
3 points
24 points*
*Points will be deducted for late papers, poor evaluations, unprofessionalism, irresponsibility, not
meeting on a regular basis, not completing the required hours, etc.
Journal 12 (your final journal)
Your last journal should include a reflection of the entire semester. In your reflection, make sure to
discuss how you have grown and changed during this experience. What have you learned regarding
people with special needs? This final journal should be about one page in length.
Thank-you Letter
Write a one-page thank-you letter to your child’s parent/supervisor/teacher. If it is more relevant, you
may write the letter directly to your assigned child or young adult. In this letter explain what you
learned from the child and discuss what you gained from this experience. This letter will be given to
the parent/supervisor/teacher/child during the week of April 28. Points will be deducted for writing
errors (you are expected to write at an advanced college level). A copy of this letter will be submitted
to Don Myers no later than the last day of class.
Introduction Letter to Next Semester’s Student
Write a one-page letter that will be given to the SDSU student who will work with your child/young
adult next semester. In this letter introduce the child/young adult to the student. Discuss ideas for
connecting with your child and ideas for activities. Lastly, suggest how the new student can “break the
ice” at the beginning of the semester. If you are working at a school or agency, your letter should
introduce the school, the agency, the teacher, and/or the supervisor. You should also give suggestions
for a successful experience at the agency or school. This letter will be given to Don Myers on
May 1 and will be saved for next semester’s student. Again, you are expected to write at an advanced
college level.
Course Projects
In Dr. Myers’ class, students will complete papers and projects. Oftentimes, the parents of the children
will allow students to borrow books, brochures, pamphlets, photo albums, scrapbooks, etc. to assist in
completing assignments. These items must be returned to the parents by the last day of class. Failing
to return their items will result in a lower grade.
End-of-Year Party
We will hold a celebration dinner in May. All the children, young adults, families, teachers, and
supervisors are invited. We serve dinner, have fun, and show a slide presentation of all the students
and their children/young adults. This is a wonderful evening, so plan to come back in May and
celebrate with us! Make sure to save some great photos of you and your assigned child/young adult so
we may include them in the May slide show.
Questions, Problems, Concerns
Please contact Don Myers with questions, problems, or concerns by telephone or Email. If something
is urgent, contact Don Myers immediately via Email.
Calendar
Date
Agenda/Assignment Due
8/27
*Submit Lab Request Form, Student Contact Information Form, proof of prerequisites (including Portfolio
Agreement), and copy of negative TB test
*Begin checking email for your lab placement, then do an Internet search of your child’s diagnosis or of your
assigned agency or school, and contact your assigned child’s parent/teacher/supervisor right away to arrange your
first meeting (make sure to have your first meeting no later than Monday, September 10)
9/3
*Dr. Myers will give you the letter of introduction from last semester’s student
9/17
*First journal and log due by 1:30pm in 401
*Release of Liability Form and second journal and log due
9/24
*Second journal due
10/1
*Third journal and log due
10/8
*Fourth journal and log due
10/15
*Fifth journal and log due
10/22
*Sixth journal and log due
10/29
*Seventh journal and log due
11/5
*Eighth journal and log due
11/12
*Ninth journal and log due
11/19
*Tenth journal and log due
11/26
*Eleventh journal and log due
12/3
*Submit thank-you letter to parent/supervisor/teacher this week
*Twelfth journal (see instructions for this journal in syllabus) and log, copy of thank-you letter, and introduction
letter to new student due
12/10
Last class
Lab Placement Opportunities
Promising Futures
This facility has several group homes for young adults with developmental delays and autism. Their facilities are in East
County and in Ramona. They have flexible hours, including nights and weekends. Students will select one client to work
with on a weekly basis. At the beginning of the semester, meet with your client and his/her supervisor and come up with a
weekly schedule and plan activities for each visit. These activities should be based on your client’s interests. In the past,
students have played basketball, baked cookies, played board games, made crafts, learned dances, done art activities, etc.
Please put your plans in writing and give one to your client and one to his/her supervisor. You need to stick with this
schedule for the entire semester. Students will attend a two-hour orientation meeting before beginning their work with the
clients. Take a copy of your negative TB screen to your first visit.
Nicoloff Elementary School
This is an elementary school in San Ysidro which also educates children with special needs. Students may work in a
Resource Specialist Program (RSP) classroom, in a Special Day Class (SDC), or in a general education (GE) class with a
child with special needs. School is in session between 8 a.m. and 2:25 p.m., except on Wednesday when school is out at
1:25 p.m. Check their web site to review their academic calendar and holidays to make sure you will be able to complete all
your hours. Students who work here must attend a mandatory 45-minute orientation on Friday, August 31. The meeting
will take place at 7:30 a.m. Take a copy of your negative TB screen to the orientation meeting. It is helpful if students
speak Spanish, but not necessary. If you work at this school, you will NOT be able to take photographs of the children for
your presentation. Also, please DO NOT contact the children’s parents to seek permission for photographs.
Alcott School and Infant Toddler Program
Up to three students may work here. This is an elementary school which includes children with disabilities and an
infant/toddler program for children with disabilities. They are located near the 1-5 and Freeway 52 merge. Students
working in the infant/toddler program will work in the mornings. Students who work in the elementary school may work
between 9am to 2pm (not during lunch). Check their web site to review their academic schedule and holidays to make sure
you will be able to complete all your hours. A copy of a negative TB clearance must be taken to the first meeting at the
school. Students will assist with the entire class, but may concentrate on one child.
Grossmont High School Special Education Class
Up to 3 students.
Clairemont High School Special Education Clasee
Up to 3 students
Sophie (14 years). She lives in Mira Mesa.
She has developmental delays and mild mental retardation due to spina bifida.
She is very sweet, very friendly, and likes to talk. Her interests are playing at the park, playing with dolls, cooking, team
sports - mainly soccer and baseball (the special challenger divisions of each), listening to music, bike riding and scooters.
Sophie’s student should visit her on weekdays after 3pm. They prefer a female student who will spend time with her doing
arts/crafts, playing Wii, and playing outdoors.
Julia (20 years). She lives in El Cajon.
She has Down Syndrome.
She enjoys music, television, her dogs, and hanging out and talking. They would like a female student who is active,
patient, with a good sense of humor. They have enjoyed students who bring craft activities to do with Julia. The student
needs to visit Wednesday or Friday after 2pm.
David I. (14 years). He lives in El Cajon.
He has Down Syndrome.
They would like a student who is active, playful, and patient. They also like a student to come with activities to do with
David. Mondays after 4:30pm and weekends work the best for this family.
Sebastian (14 years). He lives in Scripps Ranch.
He has mental retardation.
Sebastian is non-verbal, but communicates with signs, a communication board, written words, etc. He loves to ride his
scooter and take his dog for walks. He also loves music, playing board games, and likes to write. He is working on his
math skills. Sebastian communicates in English and in Spanish. They would like a student who will hang out and play and
sometimes help with homework. Weekdays after 4pm are when Sebastian is available. He could also do weekend
mornings, but weekdays after 4pm are best.
Charles (18 years). He lives in El Cajon.
He has spastic cerebral palsy and has difficulties with motor skills and speech.
Charles enjoys watching television and music. If a student plays a musical instrument, that would be great, but is certainly
not necessary. Charles has a fairly open schedule or his student can visit on Tuesday/Thursday evenings during his therapy
in Peterson Gym at SDSU (6 p.m. to 7:15 p.m.).
Alicia (20 years). She lives in San Carlos.
She has Down Syndrome.
They would like a young, outgoing, active, sporty female student. Alicia also plays the piano, so a musical student would be
nice, but not necessary. Wednesday afternoons, around 12:30pm, are when Alicia is available. Alicia likes to go bowling,
swimming, and shopping with her student.
Tim (16 years). He lives in Clairemont.
He has William’s Syndrome.
He is “all boy” and is very active and enjoys sports. They would prefer a male student with a lot of energy who enjoys
sports, but an athletic, active female will be fine. Weekends are best for this family, but weekday afternoons and evenings
may work, too. They are typically very flexible in arranging time for Tim’s student.
Roland (10 years). He lives in South Park.
He has Down Syndrome.
Roland enjoys music, books, computers, cars, swimming, going to the park, and going for walks. They would like a female
student who is fun, active, and interested in engaging Roland in different activities. They would also like the student to
work on Roland’s speech. He is available Tuesdays and Thursdays around 4pm.
Brandon Kover (19 years). He lives in La Mesa.
He has ataxic cerebral palsy.
He has unclear speech and uses a keyboard to help with his communication. He uses a wheelchair outside and walks with
assistance inside. They would like a student who enjoys video games, computer games, and board games. This student
must be reliable and show up when expected. Brandon is available all day Monday and Friday.
Bobby and Daniel Collins (23 years and 20 years). They live in Santee.
They have Duchenne Muscular Dystrophy.
Two students will come together to work with Bobby and Daniel (they prefer male students). They would like students to
visit weekdays after 1pm, but they can be flexible. They want students who enjoy sports, board games, and are outgoing
and friendly.
Paul (18 years). He lives in La Mesa.
He has severe cerebral palsy.
Paul cannot speak, he is in a wheelchair, and he has a G-tube for feeding. They want a student to observe and help with his
physical therapy on Tuesday and Thursday at SDSU in Peterson Gym (6 p.m. to 7:15 p.m.).
Katie (23 years). She lives in El Cajon.
Katie has developmental delays.
They would like a female student who is young, fun, and active and who would enjoy taking Katie on outings like going
shopping, miniature golf, etc. Katie also enjoys watching movies, doing puzzles, and making crafts. Katie’s student will
need to visit on Monday or Friday after 3pm or Tuesday, arriving no later than 3pm.
Annie (26 years). She lives in Santee.
She has Down Syndrome.
They would like a female student who is outgoing and can motivate Annie to exercise and do active activities. They would
also like the student to spark conversation with Annie, because she is quiet. Annie has a dog, so the student must like dogs.
Other activities that Annie and her student can do are puzzles, art, crafts, cooking, and board games. A student may work
with Annie Monday through Thursdays at 3:30pm or later.
Sean F. (20 years). He lives near Qualcomm Stadium.
He has cerebral palsy.
He walks and talks (a little hard to understand). Sean enjoys photography and scrapbooking. They would like a female
student who has lots of energy and likes dogs (Sean has a companion dog). Afternoons and weekends are when a student
may visit Sean.
Jack (14 years). He lives in Pacific Beach.
He has Down syndrome.
They would like a student who is engaging and patient and enjoys sports and playing games and would sometimes help with
homework. Jack is available on Tuesdays, Wednesdays, or Fridays after 4pm or on the weekends.
Jessie (9 years). She lives close to SDSU (but not within walking distance).
She has ADD, ADHD, anxiety, Asperger syndrome, and sensory issues.
They would like a student who is patient, calm, kind, tolerant, mellow, and understanding and who would enjoy playing
with Jessie and her younger brother. Students may visit Jessie on the weekends or after 4pm during the week.
Brandon Knepher (9 years). He lives in La Mesa in the Mt. Helix area.
He has hypotonic cerebral palsy, autism, and epilepsy. He is also nonverbal.
Brandon enjoys swimming, swinging, cause/effect toys, music, horseback riding, and playgrounds. They would like a
student to be Brandon’s buddy, who is patient, kind, and sensitive. Brandon also needs help on his social interaction and
turn-taking. Brandon is available on Tuesday, Thursday, and Friday afternoons.
Austin (15 years). He lives in Santee.
He has autism, ADHD, and epilepsy.
Austin enjoys riding his bike and scooter. He likes swimming, hiking, fishing, and Challenger Baseball. He wants to learn
to play guitar and keyboard. He enjoys singing and card games (Go Fish, 21, and Uno). They would like an active student
who can exercise with Austin, take him fishing, bowling, or hiking (he needs a lot of encouragement to get motivated to do
things). Austin is available during the week after school around 3pm.
Eric (11 years). He lives in Scripps Ranch.
He has autism spectrum disorder (PDD-NOS).
Eric enjoys Lego blocks, Pokémon, fencing, playing chess, and archery. He LOVES animals! They have a dog (a Pug).
They would like a student who enjoys physical activity. He responds well to humor, so a student who finds the humor in life
would be a plus. The best time to visit Eric is Saturday.
Nicholas B. (7 years). He lives in La Mesa.
He has autism spectrum disorder.
Nicholas enjoys singing, drawing, and building blocks. They would like a student to play with Nicholas with his toys and
teach him how to use his imagination in pretend play and maybe play some simple games like hide and seek, catch the ball,
etc. They would also like his student to help him with his language skills. Weekdays around 4pm are when a student may
visit Nicholas.
Sydney (17 years). She lives in Lemon Grove.
Sydney has mild autism and vision impairment (limited vision in left eye, blind in right eye).
Sydney loves art, singing, music, gardening, bowling, cooking, books, and computers. She is also very passionate about
recycling and the environment. They want a student who is energetic, sensitive, likes the outdoors, likes to cook/bake, and
enjoys music. The weekends work well for this family, as well as Friday afternoons/evenings.
Ricky (13 years). He lives in Kensington.
Ricky has autism, mental retardation, and epilepsy.
He enjoys music, cooking, and riding his bike and scooter. They would like a student who is active and enjoys music
(playing an instrument would be nice). They would also like a student to sometimes read with Ricky. Weekdays around
3:30 p.m. (not Monday or Wednesday) or most weekends are the times Ricky is available. Ricky’s student will be able to
sometimes go to his therapies (very interesting).
Haylie (17 years). She lives in Mira Mesa.
Haylie has trisomy 16. As a result, she has mental retardation and academic delays.
They would like a student to assist with her reading and to have fun with her. She likes singing, dancing, baseball, soccer,
karate, bike riding, and acting. A musical student would be nice, but certainly not necessary. Monday, Wednesday, and
Friday after 4pm and weekends are the times when Haylie is available.
Zain (7 years). He lives in Rancho Penasquitos.
He has moderate to severe hearing loss.
Zain is an active boy who enjoys soccer, going to the park, doing art, cooking, etc. He loves to be around people. They
would like a student to plan activities each week. They would also like a student interested in hearing loss. Knowing ASL
is a plus, but not necessary (Zain does not communicate using ASL). Zain is available Monday, Tuesday, and Thursday
between 3pm and 7:30pm and on Friday between 2pm and 7:30pm.
Ibrahim (Ibby) (2 years). He lives in Rancho Penasquitos.
He has moderate to severe hearing loss.
He is available 9:30am to 2pm Monday through Thursday. He is delayed in his language and they would like a student who
likes to talk and would like to work with Ibby on his language skills. They want a student who loves toddlers and likes to
get on the floor and play. Knowing ASL is a plus, but not necessary.
Jaime (22 years). She lives in the Clairemont area of San Diego.
She has cerebral palsy.
Jaime enjoys pop music, movies, reading, and Wii games. She really enjoys Disney on Ice shows. She also likes to talk on
the phone and text. Friday nights are usually good for Jaime, as well as most weekends.
Sean O. (9 years). He lives in Spring Valley.
He has Down Syndrome.
Sean loves music, playing at the playground, swimming, horseback riding, soccer, and Hot Wheel cars. They would prefer
a male student, but a female is fine. They want a student to play with Sean and have fun with him. Sean is available
Tuesdays 2pm or later, Wednesdays 4pm or later, and Thursdays 4pm or later. Weekends might work, too.
Caroline (21 years). She lives in Mira Mesa.
She has Down Syndrome.
She likes watching movies, singing, surfing the Internet, bowling, going to restaurants, all things “Disney,” Facebook, and
playing golf. They want a female student who likes dogs (they have a dog). Caroline is available weekdays after 2pm.
Caroline’s student may also join her on the weekends for her many sports and social events.
Zach (29 years). He lives in Crown Point (near Sea World).
He has cerebral palsy.
Zach walks with a cane, is a one arm golfer, rides a 2 wheel bike and enjoys bowling. He has visual processing difficulty so
he is not a functional reader. He plays video games with 2 fingers and types on the computer with one finger. He can figure
things out on computers pretty well, but not compose email. Zach has an annual pass to Sea World so he and his student
can visit Sea World (no cost to student). They would prefer a male student. He is available most afternoons and evenings
(including the weekends).
Michael (20 years). He lives near SDSU.
He has autism (high functioning).
Michael enjoys singing, reading, going to the movies, drama, the entertainment field, computers, and video games. They
would like a female student who is patient and is interested in movies and is a good communicator. They would like a
student on Wednesday afternoon or evenings.
Denise (12 years). She lives in Lemon Grove.
She has autism.
Denise enjoys shopping, movies, books, dancing, amusement parks, going to the zoo, bike riding, photography, computers,
basketball, etc. They would like an active, friendly, outgoing student who loves music, dancing, sports, and is computer
savvy. Weekends, or Mondays and Tuesdays after 3:30pm are good times for Denise, but they can be flexible.
Leilani (14 years). She lives in West Clairemont/Bay Ho area.
She has autism.
Leilani enjoys crafts, shopping, dancing, dogs, movies, boogie-boarding, and baking. They would like a female student who
is active, kind, patient, big-hearted, and likes “girly” things. The student should also be able to explain things well. The
best times for Leilani are Monday, 3pm to 5pm and Tuesday, 3pm to 6pm. Some Saturday afternoons might also work.
Zachary (4 years). He lives in Normal Heights.
He has autism.
Zachary is nonverbal and is learning to walk. He enjoys books, going to the park, and he likes Clifford the Big Red Dog.
They want a female student who has a cheerful and playful personality and is confident and secure in her skills, ability, and
personality. It would be nice if the student is knowledgeable in autism. A nervous student will not be a good match for
Zachary. The best time for Zack is Monday, Tuesday, Thursday, or Friday after 4pm and some Saturdays in the after noon
(after 1pm).
SAN DIEGO STATE UNIVERSITY
Child and Family Development 590
Weekly Family/Agency Visit Log
Week #
Is this a makeup visit for a missed week?
If yes, for week #
.
Yes
No
SDSU Student’s Name
Agency or Child Name (child’s first and last name)
Date student worked
Time student arrived
*Parent/Caregiver/Teacher Signature
Time student left
Date
*(Please do not sign until this form is completed in full with date and beginning/ending
times)
Relationship to Child
If student was unable to visit his/her family or agency, please note the reason below.
CFD 590
Lab Request Form
(Please complete this form and submit to Don Myers by 1/24 at 1:00pm in EBA 401)
Name:
Email address:
Red ID Number:
(please write clearly)
List in order your choices for the lab class.
1.
2.
3.
4.
5.
Do you have special qualities that will assist with your placement (speak a language other than English, know ASL, play a
musical instrument, have worked with autistic children, etc.)?
Is there anything else that will assist with your placement (live in North County, don’t have a car, etc.)?
CFD 590 - Student Contact Information Form
(Please complete only the first two lines below and submit to Dr. Myers on the first day of class)
Student name:
Email address:
Cell phone number:
Journal on Time?
Journal 1 Yes [ ] No [ ]
Journal 2 Yes [ ] No [ ]
Journal 3 Yes [ ] No [ ]
Journal 4 Yes [ ] No [ ]
Journal 5 Yes [ ] No [ ]
Journal 6 Yes [ ] No [ ]
Journal 7 Yes [ ] No [ ]
Journal 8 Yes [ ] No [ ]
Journal 9 Yes [ ] No [ ]
Journal 10 Yes [ ] No [ ]
Hours/Minutes
HRS
HRS
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HRS
HRS
HRS
HRS
HRS
HRS
HRS
HRS
HRS
HRS
HRS
HRS
HRS
HRS
HRS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
Comments
Journal 11 Yes [ ] No [ ]
Journal 12 Yes [ ] No [ ]
TOTAL TIME
HRS
HRS
HRS
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HRS
HRS
HRS
HRS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
MINS
Warning, Waiver, and Release of Liability
I understand that participation in CFD 590 during the Fall 2012 semester requires participating in off-campus
community service.
I hereby waive, release and discharge any and all claims for damages for death, personal injury or property
damage which I may have, or which hereafter accrue to me, against San Diego State University, Pamela
Gardner, Don Myers, and _____________________________________ as a result of my
(CFD 590 Placement)
participation in community service. This release is intended to discharge the University, its trustees, officers,
employees, and volunteers, and any public agencies from and against any and all liability arising out of or
connected in any way with my participation in the event. I further understand that accidents and injuries can
arise out of the event which may cause personal injury; knowing the risks, nevertheless, I hereby agree to
assume risks and to release and to hold harmless all of the persons or agencies mentioned above who might
otherwise be liable to me (or my heirs or assignees) for damages. It is further understood and agreed that this
waiver, release and assumption of risk is to be binding on my heirs and assigns. It is the intention of the parties
hereto that the provisions of this paragraph be interpreted to impose on each party responsible for their own
negligence.
I acknowledge that I have been fully informed of the risks and dangers involved in this Community Service
class. I have been made aware that when using my own vehicle I must have current automobile insurance.
I acknowledge that I have read and fully understood the above Warning, Waiver, and Release of Liability.
I further acknowledge that the reasons for my being requested to sign this Release have been fully explained to
me and I understand them.
I am signing this Release of my own free will and I have not been influenced or coerced by any representative
or employee of the State (students under age of eighteen (18) must have the signature of their parent or
guardian).
Participant’s Name (print):
Participant’s Signature
Red ID #
Emergency Contact Information (Name and Phone Number)
Date