ASD Affinity Program Application

Office of Admissions

- Return to ASD Affinity Program


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.



Applicant Name
   
Mailing Address
City State Zip/Postal Code
County Country  
           
Phone Number Email
           
Date of Birth        
           
Gender Female     Male  

 

Have you ever lived away from home before?


If yes, please explain.
 

Have you ever stayed more than one night away from your parents/guardians?
or university(ies)?


If yes, please explain.

Have you been hospitalized for psychiatric reasons in the last five years?


If yes, please explain.
 


Have you been involved in any documented instances of aggression in the last 5 years?


If yes, please explain.

Have you ever had a job where you earned a paycheck?


If yes, please explain.
 


Have you ever done any volunteer work?


If yes, please explain.
 


Have you taken any college classes before?


If yes please tell us where and describe your experience.


What are some of your strengths?
 


How do you learn best? What is the best way for someone to teach you something new?


What are some things that are difficult for you?
 


Have you ever had a substance abuse problem (e.g., addiction or abuse of drugs or alcohol)?


If yes, please explain.

Have you completed and submitted your application for Defiance College?



Please use the space below to write any additional information that you think is important for us to know about you.


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
Making a simple meal. Examples of simple meals are things like canned soup, a sandwich, frozen pizza, or a salad.
Cooking a meal that requires multiple ingredients. Examples of meals you might need to cook include hamburger helper, tacos, or homemade chili.
Grocery shopping for the food you will need for 1 week.
Shopping for thing you need other than food. Examples of other things you might need include paper towels, toilet paper, laundry soap, shampoo, razors, deodorant, and toothpaste.
Doing laundry.
Waking up on time and getting ready for the day.
Using public transportation. Examples of public transportation included buses, trains, and taxis.
Using kitchen appliances. Examples of kitchen appliances include an electric range, an oven, a microwave, and a blender.
General up-keep of living space. General up keep includes wiping down counters, vacuuming, mopping, cleaning the bathroom, and taking out the garbage.
Washing dishes.

Health, Wellness, and Personal Safety PL-0 PL-1 PL-2 PL-3 PL-4 N/A
Maintaining good personal hygiene. Examples of good personal hygiene practices are brushing your teeth and showering regularly, washing your hands after using the bathroom, and wearing clean clothes.
Scheduling medical appointments. Examples of medical appointments are check-ups with the doctor, dentist appointments, or an appointment with your psychologist/psychiatrist.
Treating minor injuries at home. Examples of treating minor injuries include scrapes, first degree burns, splinters, and insect bites.
Identifying and taking appropriate over the counter medications for minor ailments. Examples of minor ailments include headache, congestion, and heart burn.
Taking any regular medications. Regular medications are medications that you take every day.
Responding appropriately to fire or fire alarms.

Money Management PL-0 PL-1 PL-2 PL-3 PL-4 N/A
Opening a bank account and checking a bank statement.
Using a debit card or check book.
Using an ATM.
Using and paying a credit card.
Paying household bills. Examples of household bills are a cable bill, an electric bill, or an internet bill.
Counting money.

Interpersonal/Communication Skills PL-0 PL-1 PL-2 PL-3 PL-4 N/A
Meeting new people and starting conversations with them.
Asking my peers for clarification when I am unsure what they mean.
Asking authority figures for clarification or help when I don’t understand something. Examples of authority figures are professors and supervisors.
Asking people in the community, who I don’t know, for assistance. Examples of people in the community are servers at restaurants and cashiers at the store.
Making plans to hang out with someone socially.
Using Technology to connect with classmates and friends. Examples would be texting, facebook, twitter, and instagram.
Navigating your way through a crowded area like a cafeteria or busy hallway.
Ordering food at a restaurant.
Standing up for myself in an assertive manner without being verbally or physically aggressive.
Finding resources in the community by using the internet, yellow pages, or other publically available sources.
Understanding who to share personal information with and who not to.
Accepting feedback or correction from others in an appropriate way.





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.


After completing the performance level checklist please use the space below to provide any additional information that you think is relevant for us to know about your son or daughter.


Life Skills PL-0 PL-1 PL-2 PL-3 PL-4 N/A
Making a simple meal. Examples of simple meals are things like canned soup, a sandwich, frozen pizza, or a salad.
Cooking a meal that requires multiple ingredients. Examples of meals you might need to cook include hamburger helper, tacos, or homemade chili.
Grocery shopping for the food you will need for 1 week.
Shopping for thing you need other than food. Examples of other things you might need include paper towels, toilet paper, laundry soap, shampoo, razors, deodorant, and toothpaste.
Doing laundry.
Waking up on time and getting ready for the day.
Using public transportation. Examples of public transportation included buses, trains, and taxis.
Using kitchen appliances. Examples of kitchen appliances include an electric range, an oven, a microwave, and a blender.
General up-keep of living space. General up keep includes wiping down counters, vacuuming, mopping, cleaning the bathroom, and taking out the garbage.
Washing dishes.

Health, Wellness, and Personal Safety PL-0 PL-1 PL-2 PL-3 PL-4 N/A
Maintaining good personal hygiene. Examples of good personal hygiene practices are brushing your teeth and showering regularly, washing your hands after using the bathroom, and wearing clean clothes.
Scheduling medical appointments. Examples of medical appointments are check-ups with the doctor, dentist appointments, or an appointment with your psychologist/psychiatrist.
Treating minor injuries at home. Examples of treating minor injuries include scrapes, first degree burns, splinters, and insect bites.
Identifying and taking appropriate over the counter medications for minor ailments. Examples of minor ailments include headache, congestion, and heart burn.
Taking any regular medications. Regular medications are medications that you take every day.
Responding appropriately to fire or fire alarms.

Money Management PL-0 PL-1 PL-2 PL-3 PL-4 N/A
Opening a bank account and checking a bank statement.
Using a debit card or check book.
Using an ATM.
Using and paying a credit card.
Paying household bills. Examples of household bills are a cable bill, an electric bill, or an internet bill.
Counting money.

Interpersonal/Communication Skills PL-0 PL-1 PL-2 PL-3 PL-4 N/A
Meeting new people and starting conversations with them.
Asking my peers for clarification when I am unsure what they mean.
Asking authority figures for clarification or help when I don’t understand something. Examples of authority figures are professors and supervisors.
Asking people in the community, who I don’t know, for assistance. Examples of people in the community are servers at restaurants and cashiers at the store.
Making plans to hang out with someone socially.
Using Technology to connect with classmates and friends. Examples would be texting, facebook, twitter, and instagram.
Navigating your way through a crowded area like a cafeteria or busy hallway.
Ordering food at a restaurant.
Standing up for myself in an assertive manner without being verbally or physically aggressive.
Finding resources in the community by using the internet, yellow pages, or other publically available sources.
Understanding who to share personal information with and who not to.
Accepting feedback or correction from others in an appropriate way.





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

What are the academic and career goals that you hope to accomplish at Defiance College?


What are the life skills goals that you hope to accomplish at Defiance College?


What are the interpersonal and recreational goals that you hope to accomplish at Defiance College?
 
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