AUTISM KIDS COMMUNICATE

2016iPADand Proloquo2Go app

APPLICATION FORM

The Autism Community Network is proud to present an opportunity for families in the Sydney Metropolitan area raising children with an Autism Spectrum Disorder and severe communication difficulties, 4 to 8 years old, to be the recipients of an iPad, sturdy cover and Proloquo2Gosoftwareto facilitate communication for their child. Older children will be considered but priority given to 4-8 years.

This offer is possible thanks to the generous support from Lions Clubs throughout Sydney and with support from Lions International.

For successful recipients an initial 2 hour parent/ carer training program in Proloquo2Go will be provided through a designated Apple Store in Sydney, where the iPads will be distributed.

Priority will be given to members of the ACN with non-verbal children or children with limited verbal capabilities or communication difficulties. Additionally, other families who we can assist in the Sydney metropolitan area will also be eligible and are encouraged to apply.

To be considered please complete the application form and forward the requested supporting documentationby 12 June 2016to the following address:

AUTISM KIDS COMMUNICATE 2016

Autism Community Network

Address: P.O. Box 188

Riverwood NSW 2210

Tel: 02 9543 9036

Email:

Please note that applications received without the requested supporting documentation will not be considered in the above mentioned offer.

Regards,

Warren Thompson

President

Autism Community Network

Family Details

Parent/CarerName:
Address:
Contact Number: / Home / Mobile
Email Address:
Child’s Name:
Childs’ Gender: / Male / Female
Date of Birth: / Age onJan 1st 2016:
Diagnosis (ASD):
Additional (Co-morbid) Conditions: (may include ADHD/ Cognitive Delays/ Intellectual Disability/ Language Disorder/ Dyspraxia/ Gross or Fine Motor Impairments/ Sensory Processing Disorder etc.)
Are you a registered member of the ACN? / YES / NO

Please provide evidence to support the following:

  • Current residential address (utilities invoice etc.)
  • Child’s diagnosis and current communication ability(e.g. Psychologist report, Paediatrician/ GP letter, Speech Pathologist report etc.)

N.B. Do not send original documents: photocopied and scanned documents will be accepted

ABOUTYOUR CHILD

Please complete the following to assist our team learn more about your child.

1.Communication and Expression

Communication stage of your child / Please circle one number below
1
Non verbal / 2
Own Agenda stage
(seems to want to play alone, communication largely pre-intentional, you know mainly through body movements & gestures) / 3
Requester stage
(reach or take to you to what is needed, understand steps in familiar routines, (may include sounds/ some eye contact/ body movements/few words to calm, echolalia) / 4
Early Communicator stage
(starts to share interests with you, even by just looking back at you- joint attention) / 5
Partner stage
(communicates own interests and experiences, uses past/present/future tense)
Verbal capabilities of your child / Please circle one number below
1
Non-communicative
(may react to how they are feeling/ what is happening around them through facial expressions, eye movements, body movements) / 2
Sounds and gestures
(may include early sounds e.g. crying, cooing, babbling) / 3
Single words and phrases / 4
Developingsentences. Narrow interests / 5
Conversation
Full sentences
Additional details (optional):
2. Care/ Educational Setting / Please indicate (tick the box) where your child is currently placed.
A / Day-care
B / Pre-school
C / Aspect school
D / Other Additional Needs / Autism school
E / Satellite class
F / Mainstream school (infants/primary/high) with support from Aide
G / Mainstream without support
H / Home school
I / My child does not attend school yet
Other details (if relevant):
3. THERAPY / Please indicate the therapy your child currently attends.
A / Speech Therapy
B / Occupational Therapy
C / Applied Behavioural interventions(ABI) ABA etc.
D / Cognitive therapy
E / Physiotherapy
F / Hydrotherapy
G / Music Therapy
H / My child does not have external therapy
Other details (if relevant):
4. Current Communication Device/ Aids:
Please only indicate the communication aids that your child currently uses
-(if more than one is used please indicate EACH one) / B. COMPETENCY
For each device listed underCommunication Device (A) please indicate the competency level below (B)
A. Technology / Use at home only / Use at school or clinic setting only / Use at BOTH home and school/clinic / Developing
Assistance required / Competent
Can use without adult assistance
P.C. or Apple laptop/desktop computer
Smart phone (iPhone, Android)
iPad or Tablet
If you use an iPad at home please state who uses it and the main purpose
Current Apps/ programs your child uses: (please list)
Visual Aids:
(Aided /assisted communication devices)
Communication books
Communication board
Picture Exchange Communication System
Other visual picture card system
(e.g. Flash cards, board maker cards)
Speech generating devices
Name device:
Unaided communication devices
Body Language/ gestures
Sign Language

About my child’s communication:

5.My child initiates communication
1
Never / 2
Occasionally with a lot of help / 3
Regularly
with some help / 4
Usually
with minimal help / 5
Always
6.My child willinglyparticipates in communication:
1
Never / 2
Occasionally with a lot of help / 3
Regularly
with some help / 4
Usually
with minimal help / 5
Always
Other (context- needs/interest etc):
7. My child communicates the following: / 1
never / 2
Occasionally with a lot of help / 3
Regularly
with some help / 4
Usually
with minimal help / 5
Always
Requests & Routines
List examples:
Shared experiences and/or emotions:
List examples
My child does not communicate:

8. How would an iPad change the way your child communicates?

In 250-300 words or less:

Thank you for taking the time to complete this application.

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