REGIONAL TEACHING AND SUPPORT SERVICES APPLICATION FORM

If you wish to apply to access NZSL@School, please also complete the attached NZSL@School Application on page 3.

Date: / Child/Young Person’s Name:
D.O.B.: / Current Year Level:

Please attach current IEP/IDP

Pleaseattach Language and Literacy assessments and reports

and any current curriculum assessments (eg. NCEA results, asTTle, NEMP, PAT Comp, PAT Listening, unedited sample of students written language).

Attach Language assessment and Literacy assessment

Audiological:

Include a full audiological report and complete the audiogram.

Hearing Loss

Only children with a diagnosed hearing loss will be considered for

admission to the Resource Teacher of the Deaf caseloads.

ORRS Status

Very HighApplication in progress

HighNo application made

ReviewableApplication declined

High Health

Identifies as:

Maori Pacific Islander NZ/European Asian Other

New Immigrant Yes No : Year of arrival:

Hearing Aids: Cochlear Implant

Aided audiogram attached with details of hearing aids and assistive equipment used

Use of amplification:InconsistentConsistent

Current Resource Personnel:

ORRS funded Teacher Aide:hours / weekORRS funded specialist teacher (0.1/0.2) hours / week

ESW hours / week SEG Teacher Aidehours / week

SLTDRP Other:

Name of current Adviser on Deaf Children:______

Additional support: Please specify eg. SEG funded resources Other services?

Major Areas of need: (Specify Language and Literacy needs)

Social and Emotional Development

Comments
Appropriate interactions with peers in classroom/preschool settings.
Appropriate interactions with peers in informal settings.
Has good social skills.
Has good independence skills.

Speech, Language and Cognition( Scale: Y = Yes, N = No, S = Sometimes with further data where requested)

Comments
Clearly understands classroom instructions.
Clearly follows and is appropriately involved in group discussions.
Acquisition and comprehension of new language in curriculum areas will need to be specifically taught and reinforced
Speech is intelligible to the naive listener.
Age appropriate language skills.
Age appropriate cognitive development

School: ______

Contact Person: ______

Address:(full postal address) ______Post Code:______

Phone: ______Fax: ______Email: ______

Name of Parent/s / Caregiver/s: ______

Address: (full postal address) ______ Post Code:______

Phone: ______Fax: ______Email: ______

The admissions committee in considering the report on the multidisciplinary assessment of the child seeking admission to an itinerant caseload will use the following criteria. Priority will be given to:

• Child/young person who has profound, severe or moderate/severe hearing loss.
•Child/young person who has mild to moderate hearing impairment and exhibits a significant communication difficulty.
• Child between 3-8 years of age in educational settings.
• Child/young person who is late being diagnosed.
• Child/young person who is in a transitional schooling period.
• Senior students who are sitting formal examinations.
• Child/young person who has deaf or hearing-impaired parents.
•Child/young person who comes from a family where little or no English is spoken in the home.
• Child/young person has an additional condition. Specify:

The Centre has an obligation to provide professional development for staff. As a result specialist staff (SRT/DRP) may visit your child’s school with the Specialist teacher to provide advice and guidance that will support your child’s programme.

TO BE COMPLETED BY PARENT / GUARDIAN

I agree to the information provided in this request to be shared with relevant staff within van Asch Deaf Education Centre.

Signed: ______Date:______

NZSL@School Application

NB: Please refer to the NZSL@School Guidelines for information about access to NZSL@School at

  1. Child’s Language Use: Indicate the child’s primary language (the language/mode they prefer/need to use to fully access information receptively and the language/mode they prefer/need use to expressively to fully communicate with others.

Receptive Language (at School)

oNZSL

oSpoken Language

  • English
  • Te Reo
  • Other (specify) ______

Expressive Language (at school)

oNZSL

oSpoken Language

  • English
  • Te Reo
  • Other (specify) ______

Comment: Please describe any other aspects of the student’s communication that provide an overview of the student’s use of NZSL as their primary language.

______

2) Home Language

Please specify the language used at home by parents/caregivers/whānau to communicate with the child.

oNZSL

oEnglish

oTe Reo Māori

oOther (specify) ______

Comment: Please describe any other aspects of the student’s communication environment at home that provide an overview of the student’s use of NZSL as their primary language.

______

3) List the type of support and resources you believe would enable the student to access class

learning and school activities.

Examples:

  • Teacher Aide to provide NZSL communication between the student, the teacher and classroom peers
  • NZSL tuition to classroom teacher, Teacher Aide and school peers.
  • Curriculum adaptation/teaching strategies support to teacher/teacher’s aide

______

4) Describe any computer hardware and software that the student is using to support theirlearning and communication with the teacher/peers.

______

5a) Enrolled in school Yes / No

5b) If not enrolled in school, please state school start date ______

______(Principal Signature) ______(date)

______(Parent/Caregiver Signature) ______(date)

NB: If a school has not been determined by the parents at the time ofsubmittingthis application for NZSL@School,it is sufficient for parent/caregiver only to sign thisapplicationform.

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