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Posted on January 8, 2019January 8, 2019 by admin

SUNY BUFFALO STATE COLLEGE

Department of Exceptional Education

Categoriesacademic

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address

3800 Delaware Avenue Suite 103 Kenmore, NY 14217

phone

716-289-7486

Email

info.chopewny@gmail.com

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Personal Information

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School / Employer

Grade / Program

Please indicate the presence of a developmental disability, if any (check all that apply):

Autism

Epilepsy/Seizure Disorder

Intellectual Disability

Learning Disability (e.g., dyslexia, dysgraphia)

Other Neurological Impairment

Undetermined Developmental Disability

Other

Pls indicate disability

Does the applicant have care coordination?

Yes

No

To help us best accommodate the applicant, please answer the following questions as accurately as possible.

What level of support is needed for the applicant to be successful?

Shared Support

1:1 Support

Other

Does the applicant require the assistance of an aide for personal care or management needs?

Yes, 1:1 aide

Yes, shared

No

I understand that C-HOPE cannot provide assistance for personal care needs such as toileting and eating.

Did/does the applicant have a Behavior Intervention Plan (BIP)?

Yes

No

How does the applicant communicate? Check all that apply.

Verbal - carries on full conversations. Are there articulation challenges?

Verbal - carries on limited conversations. Articulation challenges?

Echolalia (repeats words and/or phrases)

Sign Language (ASL or Signed Exact English)

Gestures (other than sign language)

Augmentative/Assistive Technology - high tech

Augmentative/Assistive Technology - low tech

Others

Please indicate

Which best describes the applicant's physical abilities?

Ambulatory

Ambulatory with assistance

Wheelchair user

Does the applicant have any allergies? (e.g., medication, food, bee stings, latex, etc.)

Yes

No

If yes, please provide detail

Is an EpiPen required for any allergy?

Yes

No

If yes, please provide detail

Please list any dietary restrictions the applicant may have.

In the event of a serious emergency (e.g., fire), what is the most critical piece of information about the applicant do you want us to share with first responders?

Is the applicant fearful of or adverse to any of the following? Check all that apply and provide detail.

Loud noises

Animals/Insects

Textures

Siren/Fire Alarm

Police/Firefighter/EMT/Paramedic

Other

None of the above

Please indicate

Do any of the following frustrate the applicant? Check all that apply and provide detail, as necessary.

Noise

Raised voices

Touch/Touching

Bright lights

Cold temperature

Hot temperature

Other

None of the above

Please indicate

Are there any key words, phrases, or other stimuli that should or should not be used with or around the applicant?

Please list requested accommodations. C-HOPE willl consider requests as program limitations allow.

Please list interests and hobbies of the applicant.

In order to maximize the applicant's experience in this program, please provide additional information that would be valuable for C-HOPE staff to know.

PARENT / GUARDIAN INFORMATION

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Street Address City State / Province / Region ZIP / Postal Code

EMERGENCY CONTACT INFORMATION

Contact #1

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Relationship to the applicant

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Home Phone

Permission

I give permission to Contact #1 to pick up applicant

Contact #2

Name(Required)

First Last

Relationship to the applicant

Cellphone(Required)

Home Phone

Permission

I give permission to Contact #1 to pick up applicant

Please be sure to include the following with your application:

Program application

$25 non-refundable deposit (checks payable to C-HOPE Inc.)

Consent/Release forms

Medication self-carry/administer documentation, if applicable

Email

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