Hello, Thank you for your interest in the College Supports Program (CSP) at the Eastern Michigan University! The program is designed to support students with Autism Spectrum Disorder as they transition into college and through completion of their degree. Students accepted into our program must first be admitted into Eastern Michigan University on their own merit and have the ability to succeed in college but require more help than their typical peers to complete a college degree. Each student receives support in academics, accommodations, independent living, healthy living and social skills. The fee-­‐based program works in conjunction with the many free supports offered through the EMU Disability Resource Center (DRC). Academics: Students receive assistance in designing their academic programs, registering for classes, and making schedule changes. The CSP staff is available to facilitate communication with professors regarding class requirements and any classroom behavior issues that might need to be addressed. One-­‐on-­‐one mentors help students with course material and in meeting due dates of classroom assignments. Mentors may also attend classes with a student as needed. Accommodations: CSP staff works closely with the EMU Disability Resource Center to ensure that appropriate accommodations are provided. Accommodations may include note taking, taking quizzes and exams in a non-­‐
distractive setting, and/or extended time for tests. CSP staff also provides study tables and drop-­‐in tutoring hours in addition to those provided by the Holman Success Center. Independent Living: CSP staff assists students to develop the skills necessary to live independently such as maintaining their dorm room, doing laundry, organizational skills, and time management. Staff also helps students develop self-­‐advocacy skills in a variety of ways such as accompanying students to their professors’ office hours to ask for assistance. Healthy Living: CSP staff may assist with medication management, weekly fitness programs, diet/nutrition, as well as healthy and safe adult relationships. Social Skills: Social skills education is built into all aspects of the program. The goal is to integrate every student fully into life at Eastern Michigan University. Program staff assists students in participating in any social, sporting, theater, or special event on campus that might be interesting to our students. In addition, the program creates unique social events for the students to spend time together. The ultimate goal for each student who is part of the program is to graduate having had a full, typical, college experience. The scope of the support offered and skills taught not only help our students graduate, but also ensure that they will be successful, productive, and happy citizens at EMU and for the rest of their lives. If you need additional assistance or have questions, please feel free to contact our office. Thank you. Pamela Lemerand pamela.lemerand@emich.edu Directors – Dr. Sally Burton-­‐Hoyle and Dr. Pamela Lemerand and • Coordinator – Callie Boik 319 B Porter Hall • Ypsilanti, MI 48197 • P: 734-­‐487-­‐6483 • F: 734-­‐487-­‐2473 1 APPLICATION Please complete the attached application, and return it with the supplemental documentation* to: Dr. Pamela Lemerand Eastern Michigan University Director, College Supports Program 319 B Porter Hall Ypsilanti, MI 48197 Email: pamela.lemerand@emich.edu or college_support@emich.edu Phone: 734-­‐487-­‐6483 *Supplemental documentation includes: • Current (within the past 3 years) evaluations in the areas of cognition including intelligence; • Evidence of academic achievement in the form of grades(transcripts/report cards) and standardized achievement tests: • Last or current IEP: • Phone interviews by the College Supports Program with high school or college personnel, if possible; • School behavior intervention plans: and • Letters of support from current teachers, if the student i s still attending high school. Student Information First and Last Name: ____________________________________________________________________ Nickname or the name you prefer to be called: _______________________________________________ Address: ______________________________________________________________________________ City:______________________________ State: ___________________ Zip Code:___________________ Home Phone: __________________________ Cell Phone: _____________________________________ Email: _______________________________________________________________________________ Date of Birth: _____________/_____________/_____________ Age: ______________ Sex: M F 2 Parent/Guardian Information Father’s Name: _________________________________ Father’s Cell Phone: _____________________ Father’s Email: ___________________________________________________________________________ Mother’s Name: _______________________________ Mother’s Cell Phone: _____________________ Mother’s Email: __________________________________________________________________________ Family address, if different from student: Address: ____________________________________________________________________________ City:________________________________ State: ______________ Zip Code:_____________________ Sibling Information Name Age Diagnostic Information Please check off the autism spectrum diagnosis (ASD) you have received that makes you eligible for the College Supports Program: ¨ Asperger’s Disorder ¨ Autism Spectrum Disorder ¨ Non-­‐Verbal Learning Disability ¨ Pervasive Developmental Disorder-­‐Not Otherwise Specified (PDD NOS) Please list any additional diagnoses that have been formally assessed: ¨ ADHD ¨ Depression Disorder ¨ Bipolar Disorder ¨ Anxiety ¨ Other (please explain)_____________________________ 3 Please list the name and contact information of the licensed professional who provided the ASD diagnosis, along with the date the diagnosis was given. Provider’s Name: _________________________________Date of Diagnosis_______/______/______ Address: ___________________________________________________________________________ City: _____________________________________State:__________ Zip Code:___________________ Email: _____________________________________________________________________________ Phone Number: _____________________________________________________________________ What type of professional provided the diagnosis? (Check one):  Psychologist  Psychiatrist  Neurologist  Other (please  Physician explain)__________________________________ Do you currently receive support services in school? (For example: tutoring or special services for autism spectrum disorder -­‐ learning disabilities; speech and language therapy; occupational therapy, extra time on tests, note taker, social skills group) No  Yes  (If “Yes,” please explain briefly what services you receive) Do you currently receive services, privately, from a psychologist, social worker, or psychiatrist? No  Yes  (If “Yes,” please explain briefly what services you receive and the focus of the service) 4 Personal Statement I learn best when: My academic strengths include: My academic challenges include: My special academic interests include: 5 I am interested in attending Eastern Michigan University because: I am nervous about attending Eastern Michigan University because: If I enroll at Eastern Michigan University I think I will need help with: (try to be specific) Please share any additional information and/or interesting things about yourself that you would like us to know about: 6 Education Information Please list in chronological order the high school and colleges you have attended, beginning with the most recent. Please note any diplomas or types of certificates you have received. Name of School Dates Attended Address Certificate/Diploma Please indicate the following grades and test scores : High School GPA:___________ ACT/SAT scores: ___________ If applicable, College GPA: ___________ Discuss your special interests outside of school: What do you do in your free time? 7 What teams, clubs or organizations are you currently involved in? Please share accomplishments that you are most proud of: Consent I agree to allow the College Supports Program staff at Eastern Michigan University to provide my name, and the fact that I am applying to the College Support Program for support, to the University’s Admissions Office and the Disability Resource Center. Signature: ____________________________________________________ Date: _____________________ Printed Name: ___________________________________________________________________________ Parent/Guardian Signature if applicant is under 18 years of age Signature: ____________________________________________________ Date: _____________________ Printed Name: ___________________________________________________________________________ Thank you for applying to the College Supports Program. After our office receives all of your materials, you will be contacted to schedule an interview. Please note, you must apply directly to Eastern Michigan University before acceptance into the College Supports Program. Undergraduate admissions http://www.emich.edu/admissions/ Phone: 800-­‐468-­‐6368 Graduate school admissions http://www.emich.edu/graduate/admissions/ Phone: 734-­‐482-­‐3400 8 Eastern Michigan University College Supports Program Parent Input Document STUDENT NAME: ______________________________________________________________________ YOUR NAME: _________________________________________________________________________ STUDENT’S DATE OF BIRTH: ________________________ AGE: ______________ SEX: MALE FEMALE YOUR CELL PHONE: __________________________ YOUR HOME PHONE: _______________________ YOUR EMAIL ADDRESS: _________________________________________________________________ CONTACT PERSON AT CURRENT HIGH SCHOOL: _____________________________________________ TITLE: _______________________________ PHONE NUMBER: ________________________________ EDUCATIONAL HISTORY -­‐ Please answer from your perspective CURRENT ACADEMIC ACCOMODATIONS: ___________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ACADEMIC STRENGTHS/BEST SUBJECTS: ___________________________________________________ ACADEMIC WEAKNESSES/DIFFICULT SUBJECTS: _____________________________________________ PLEASE BRIEFLY DESCRIBE THE STUDENT’S STUDY SKILLS AND HABITS: __________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ PLEASE BRIEFLY DESCRIBE ANY SUPPORTS YOU (THE PARENT) PROVIDE TO ASSIST THE STUDENT WITH SCHOOL WORK (Please be specific: checking homework, organizing projects, monitoring due dates, etc.) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ WHAT DO YOU BELIEVE WILL BE THE TWO GREATEST CHALLENGES TO YOUR STUDENT’S SUCCESS AT COLLEGE? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 9 IF YOUR STUDENT PLANS TO LIVE IN THE DORM, PLEASE ANSWER THE FOLLOWING QUESTIONS: ▪
DOES THE STUDENT WAKE UP AND GET READY FOR SCHOOL INDEPENDENTLY? YES _____ NO _____ IF NO, WHAT HAPPENS NOW EACH MORNING? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ▪
DOES THE STUDENT SHOWER AND WASH HAIR REGULARLY? YES _____ NO _____ HOW MUCH “REMINDING” MUST YOU DO? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ▪
CAN THE STUDENT INDEPENDENTLY MANAGE ORGANIZING AND TAKING MEDICATION? YES _____ NO _____ IF NO, WHAT HAPPENS NOW? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ▪
PLEASE CIRCLE THE WORD THAT BEST DESCRIBES THE CONDITION OF THE STUDENT’S BEDROOM: COMPULSIVELY ORGANIZED ORGANIZED AVERAGE CHAOTIC ▪
TOTAL CHAOS DOES THE STUDENT TEND TO STAY UP ALL NIGHT ON THE INTERNET? YES _____ NO _____ IF YES, WHAT IS THE STUDENT DOING ON THE INTERNET? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ DIAGNOSTIC HISTORY Please attach copies of relevant documents, including evaluation reports PRIMARY DIAGNOSIS AUTISM ____ ASPERGER’S SYNDROME ____ PDD-­‐NOS ____ OTHER ___________________________ DATE OF DIAGNOSIS: _______________________________________ AGE: _______________________ NAME AND TITLE OF PERSON WHO MADE THE DIAGNOSIS _____________________________________________________________________________________ _____________________________________________________________________________________ 10 ADDITIONAL DIAGNOSES (i.e. ADHD., anxiety, depression) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ MEDICAL HISTORY DOES THE STUDENT CURRENTLY TAKE MEDICATION ON A REGULAR BASIS? YES ____ NO ___ IF YES, PLEASE LIST EACH ONE BELOW: (List additional medications on back of page) MEDICATION PRESCRIBING PHYSICIAN NAME TYPE OF PHYSICIAN PHONE NUMBER PSYCHIATRIST ___________ GENERAL PHYSICIAN ______ OTHER PSYCHIATRIST ___________ GENERAL PHYSICIAN ______ OTHER PSYCHIATRIST ___________ GENERAL PHYSICIAN ______ OTHER PSYCHIATRIST ___________ GENERAL PHYSICIAN ______ OTHER PSYCHIATRIST ___________ GENERAL PHYSICIAN ______ OTHER SOCIALIZATION WHAT ARE THE STUDENT’S STRENGTHS IN THE AREA OF SOCIAL INTERACTIONS? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ WHAT SOCIAL SKILLS DOES THE STUDENT STRUGGLE WITH? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 11 WHAT EXTRACURRICULAR ACTIVITIES DOES THE STUDENT PARTICIPATE IN? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ DOES THE STUDENT HAVE FRIENDS THAT ARE SEEN CONSISTENTLY OUTSIDE OF SCHOOL HOURS? YES ____ NO ___ STUDENT STATUS INCOMING FRESHMAN _____ EXPECTED DATE OF GRADUATION: ___________________________________________________ CURRENT GPA: ___________________________________________________________________ TRANSFER STUDENT _______ PREVIOUS COLLEGE/UNIVERSITY: ____________________________________________________ GPA: _______________________ PREVIOUS MAJOR: ___________________________________ REASON FOR TRANSFER: ___________________________________________________________ HAS STUDENT BEEN ACCEPTED TO EMU? YES ____ APPLICATION PENDING _____ NO____ ANTICIPATED EMU START DATE: FALL OF __________________ WINTER OF _____________________ HAS STUDENT APPLIED FOR HOUSING? YES ____ APPLICATION PENDING _____ NO_____ HAS STUDENT APPLIED FOR DISABILITY RESOURCE CENTER SERVICES AT EMU? YES ____ APPLICATION PENDING _____ NO_____ FAMILY BACKGROUND MOTHER’S NAME: _____________________________________________________________________ OCCUPATION: _________________________________________________________________________ MOTHER’S EMAIL ADDRESS: _____________________________________________________________ MOTHER’S CELL PHONE:______________________ MOTHER’S WORK PHONE:____________________ 12 FATHER’S NAME: ______________________________________________________________________ OCCUPATION: _________________________________________________________________________ FATHER’S EMAIL ADDRESS: ______________________________________________________________ FATHER’S CELL PHONE:______________________ FATHER’S WORK PHONE:______________________ PLEASE INCLUDE ANY OTHER INFORMATION YOU WOULD LIKE US TO KNOW ABOUT YOUR STUDENT HERE: (attach additional pages as needed) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ONCE ALL MATERIALS ARE RECEIVED, YOU WILL BE CONTACTED TO SCHEDULE AN INTERVIEW. PLEASE NOTE: ALL STUDENTS MUST FIRST BE ADMITTED TO EASTERN MICHIGAN UNIVERSITY ON THEIR OWN MERIT. FOR ALL QUESTIONS OR IF YOU NEED ASSISTANCE, PLEASE CONTACT DR. Pamela Lemerand VIA PHONE AT 734-­‐487-­‐6483 OR EMAIL AT pamela.lemerand@emich.edu OR COLLEGE_SUPPORT@EMICH.EDU 13