Application for Students

For the application for parents, click here.
ASD Affinity Program

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

This is information about the applicant. This section should be completed by the applicant. The last section of this application should be completed by a parent or support person who knows the student well. 

Please note when completing 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 in encrypted (secure), so it can't be read or intercepted by other people.

Example: 7/1/1999

APPLICANT PERFORMANCE RATINGS

This is information about the applicant. This section should be completed by the applicant without input from other individuals.

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.

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 seek 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.

Please be sure to submit all supporting materials with your application. 

  • Current psychological evaluation or Evaluation Team Report (ETR) conducted within the last 3 years and including:
    • Results from intelligence testing (e.g., Stanford Binet IV, WAIS-IV)
    • Results from achievement testing (e.g., Wechsler Individual Achievement Test, Woodcock Johnson Tests of Achievement)
      Note: Results should include subtest scores and a detailed narrative.
  • Documentation of ASD diagnosis/qualification of services
  • Most recent individualized educational plan (IEP), if applicable
  • Two letters of reference from a high school teacher, counselor, therapist, and/or principal. Letters of reference should speak to your preparation for college level academics and college life. 
  • Parent or Support Person Performance Ratings

Supporting documentation can be submitted by email to autism@defiance.edu or post mail to Clarissa Barnes, ASD Affinity Program, 701 N. Clinton Street, Defiance, OH, 43512.