ASD Affinity Program Application

Office of Admissions

- Return to ASD Affinity Program


This application will not be reviewed until the following conditions are met:

 

General Information: This is information about the applicant. This section should be completed by the applicant and a parent.

Please note when filling out this form: Use the Tab button to switch from question to question, or use your mouse. Hitting the return key will submit the form. The information you provide is encrypted for security. Secure information means the information you provide, such as your SSN, is encrypted (secure) so it can't be read or intercepted by other people.



   
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Female     Male  

 





 


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Applicant Performance Ratings: This is information about the applicant. This section should be completed by the applicant without input from parents or other individuals. If the applicant has a question a parent may assist in clarifying what is being asked, but should not influence the applicant’s self-rating.

Please complete this questionnaire by selecting the performance level (PL) that you think best describes your current skill level and ability for each of the items. We will use this information to learn more about you as an individual.


Performance Level Description
PL-0 No participation – You refuse to participate in the learning opportunity. This means that you choose not to try to do an activity.
PL-1 Early Instruction – You need prompts for most, or every, step in the task. This means that you need direct 1:1 assistance to complete the task.
This means that you need someone to help you with every step of the activity.
PL-2 Guided Practice – You need specific prompts (e.g., verbal, written, gestural) to complete the task, but you do not need prompting for each step in the sequence.
This means that you need help with the activity, but that you can do some parts of it on your own.
PL-3 Guided Independence – You need general prompts to complete the task (e.g., a reminder that it is an expectation to complete the task) or you complete the task within the structure of a program (e.g., because that is part of your routine at school).
This means that when someone reminds you to do the activity or if it is a part of your routine you do it without any other help.
PL-4 Independent – You do not require additional instructions, prompting, or other assistance to complete the task. You independently seeks resources as needed.
This means that you do this activity without anyone reminding you or putting it in your schedule.
N/A You have never had the opportunity to try this.
This means that you have never been able to try the activity. This is different the PL-0.

Life Skills PL-0 PL-1 PL-2 PL-3 PL-4 N/A

Health, Wellness, and Personal Safety PL-0 PL-1 PL-2 PL-3 PL-4 N/A

Money Management PL-0 PL-1 PL-2 PL-3 PL-4 N/A

Interpersonal/Communication Skills PL-0 PL-1 PL-2 PL-3 PL-4 N/A





Parent/Guardian Performance Ratings: This is information about the applicant. This section should be completed by the parent or guardian without input from the applicant.

Please complete this questionnaire by selecting the performance level (PL) that you think best describes the applicant’s current skill level and ability for each of the items. We will use this information to learn more about the applicant as an individual.


Performance Level Description
PL-0 No participation – The applicant refuses to participate in the learning opportunity.
PL-1 Early Instruction – The applicant needs prompts for most, or every, step in the task. This means that he or she needs direct 1:1 assistance to complete the task.
PL-2 Guided Practice – The applicant need specific prompts (e.g., verbal, written, gestural) to complete the task, but he or she does not need prompting for each step in the sequence.
PL-3 Guided Independence – He or she needs general prompts to complete the task (e.g., a reminder that it is an expectation to complete the task) or the applicant completes the task within the structure of a program (e.g., because that is part of his or her routine at school).
PL-4 Independent – He or she does not require additional instructions, prompting, or other assistance to complete the task. He or she independently seeks resources as needed.
N/A He or she has never had the opportunity to demonstrate this skill.



Life Skills PL-0 PL-1 PL-2 PL-3 PL-4 N/A

Health, Wellness, and Personal Safety PL-0 PL-1 PL-2 PL-3 PL-4 N/A

Money Management PL-0 PL-1 PL-2 PL-3 PL-4 N/A

Interpersonal/Communication Skills PL-0 PL-1 PL-2 PL-3 PL-4 N/A





Goals: This is information about the applicant. This section should be completed by the applicant and a parent.