Sheila C. Johnson Center for Human Services
417 Emmet Street South
P.O. Box 400270
Charlottesville, VA 22904-4260
www.curry.edschool.virginia.edu/sjc
Phone: 434.924.7034 Fax: 434.924.4621
McGuffey Reading Center
2014 APPLICATION FOR SUMMER READING PROGRAM, JULY 7-25
* Applications will be considered upon completion and return of BOTH the application and the school form. The Center may request an additional screening as part of the process.
Client’s name: ______Age: ______Date of Birth: ______Current Grade:______
Primary Language spoken at home: ______
Parent’s or Guardian’s information:
Name: ______
Address: ______
(street, apartment number)
______
(city) (state) (zip code)
Home Phone: ______Daytime or Cell phone ______
Email address:______
Fee Discount Requested: Yes ______No ______
(Call for more information) 2013 1040 Federal Tax Form required
Fee discounts based on documented income are available. A 2013 1040 Tax form is REQUIRED. There is no guarantee of a reduced rate. Assistance is first come, first serve.
A non-refundable payment of $15.00 must accompany this completed form (and will be applied toward the program fee upon acceptance). Testing fees, tuition and processing fee for the program are $525.00. A non-refundable deposit of $250.00 is required upon acceptance, and the balance of $260.00 is to be paid in full on or before July 7, 2014. Please send all payments to: McGuffey Reading Center, Sheila Johnson Center for Human Services, P.O. Box 400270, 417 Emmet Street, S., Charlottesville, VA 22904.
Name of Person Agreeing to Pay (please print): ______
SSN of Person Agreeing to Pay: ______
Signature of Person Agreeing to Pay: ______
Date: ______Relationship to Client: ______
Academic Status
Present School: ______Phone: ______
Address: ______
(street)
______
(city) (state) (zip code)
Teacher: ______
Reading Teacher (if not the same as classroom teacher )______
Additional Services (please check all that apply):
Title I____ Speech/Language ____ *Resource (Special Education Pull-out or Push-In) ____ *Self-contained Special Education____ English Language Learner____ English as a Second Language____ In-school Tutor____ After-school Tutor____
*If Self-contained Special Education or Resource has been checked, what is the primary diagnosis? Are there any other diagnoses? ______
Has your child ever been diagnosed with Attention Deficit Disorder? Yes ______No______
Has your child ever been retained: Yes ____ No____. If yes, what grade?______
Has your child ever been to the McGuffey Reading Center? ____ If so, when? ______
Has you child been evaluated for a reading problem or any other related problem at school or elsewhere? If so, please explain.
______
______
Are you willing to share copies of the reports? Yes____ No____. If yes, please mail reports with this application.
Has your child received additional help in reading outside of school (private tutoring, etc.)? If so, please explain.
______
______
Health & Developmental History
Does your child have any health problems that we should know about? If yes, please explain.
______
Has your child ever been diagnosed with any language related problems? Yes ____ No ____. If yes, please explain.
______
Did s/he have any articulation problems? Yes ____ No____. If so, please explain. ______
______
What is his/her attitude toward reading? (please circle 1-10, 1 being extremely negative and 10 being extremely positive)
1 2 3 4 5 6 7 8 9 10
What is his/her attitude toward writing? (please circle 1-10)
1 2 3 4 5 6 7 8 9 10
What are you child’s interests? ______
In what area(s) does your child excel? ______
If your child is accepted for the McGuffey Summer Reading Program, will you guarantee full participation from July 8th to July 26th?
______
signature
Please read each release (Forms A, B, C)…page to follow.
Please also provide the following school form. In order to be considered, this form MUST be included.
RELEASE FORM A
Tutoring Request/Release Authorization:
Date: ______Name: ______
It is understood that tutoring/testing activities will be observed and reviewed by the McGuffey clinical staff and that the information will not be viewed or released to anyone without my consent.
______
Signature of client or parent/legal guardian
RELEASE FORM B
McGuffey’s report and tutoring information may be released to:
Name: ______Relationship:______
Address: ______
(Street) ______
(City) (State) (Zip code)
______
Signature of client or parent/legal guardian
Do you give us permission to contact your child’s teachers if needed? Yes ____No___ If yes, please complete Academic Status on page 2.
RELEASE FORM C
Permission to use client’s tutoring and assessment data for future research to inform researchers and teachers in the area of literacy instruction: The information will be handled confidentially. The client’s information will be assigned a code number. The list connecting this code will be kept in a locked file. Names will not be used in any report. Choosing to allow or not allow assessment information to be used for research purposes will have no impact on the tutoring process. Permission is completely voluntary, and you have the right to withdraw at any time without penalty.
______
Signature of client or parent/legal guardian
Sheila C. Johnson Center for Human Services
417 Emmet Street South
P.O. Box 400270
Charlottesville, VA 22904-4260
www.curry.edschool.virginia.edu/sjc
Phone: 434.924.7034 Fax: 434.924.4621
McGuffey Reading Center
APPLICATION FOR SUMMER READING PROGRAM
SCHOOL FORM
We are in the process of considering the student named below for the McGuffey Reading Center’s Summer Reading Program. The following information from the classroom teacher will be very helpful to us in considering the application. You may be sure that all information supplied will be held in strict confidence. Please attach extra sheets for additional information where necessary. Please return this form directly to the Center at the above address.
To be completed by student’s parent/legal guardian:
Student’s name______
School______Grade ______
School address ______
Teacher or homeroom ______Phone ______
By my signature below, I hereby give permission for school personnel to provide the requested information regarding my child, ______, to the McGuffey Reading Center for summer program application purposes.
______
Signature of parent/legal guardian
______
Date
1. Please comment on any physical, emotional, or social factors of significance: ______
______
______
2. Please indicate latest grades.
______
______
______
3. Has this student been the subject of a child study? ______If so, when ______and
what were the outcomes? (Please include a copy of the report if possible.)
______
______
4. Please describe the student’s writing achievement. Include assessment information if available.
______
______
______
______
5. Please provide student’s spelling level and achievement? Include assessment information.
______
______
______
6. Present level of reading ability and provide most recent assessment information.
______
______
______
7. Additional comments/information, which would assist in the consideration of this student:
______
______
______
* Please provide any assessment reports if possible.
______
Signature
______
Date