ࡱ > _ a ^ O4 bjbjΊ 7f 3, 8 , , ~ t , " # # 8 F : ! , ƁP. M N 0 ~ W . 2# 2# \ # # ~ 2# z : Western Kentucky University Literacy Clinic Application Form The WKU Literacy Clinic provides expert literacy assessment and tutoring for K-12 students. Literacy Assessment A comprehensive battery of individually administered literacy assessments addresses reading level, word identification, phonics, comprehension, and spelling skills. A full written report is created for each student. A small number of fee waivers are available and are awarded on a sliding scale based on financial need. Experienced teachers enrolled in our graduate program provide literacy assessments under direct supervision of faculty during the academic semester. The cost is $50 (nonrefundable). Literacy Tutoring Tutoring services are provided in a one-on-one setting with an emphasis on strategies to improve the students reading accuracy, fluency, and comprehension. Tutoring will be provided by graduate students in the Literacy MAE program at WKU. Experienced teachers enrolled in our graduate program provide literacy tutoring under direct supervision in the fall and spring academic semesters. The series of 18-week sessions for students generally start in September, with a break for the winter holiday, and begin again in February. Please note that the number of applications that we receive exceeds our ability to provide services to everyone immediately. Applications are reviewed and processed on a first come, first served basis, and will be weighed based on application date, level of need, and availability. Clients selected for tutoring each semester will be contacted by phone and email and will be asked to make a commitment to attend the full set of tutoring sessions for that year. For more information, contact me at HYPERLINK "mailto:nancy.hulan@wku.edu" nancy.hulan@wku.edu Please return this application to: Dr. Nancy Hulan School of Teacher Education Western Kentucky University 1906 College Heights Blvd. #61030 Bowling Green, KY 42101-1030 Tel: (270) 745-4324 Fax: (270) 745-6322 WKU Literacy Clinic Date of Application: __________________________ Name of Student: ____________________________________________________________ Last First Middle Age of Student: __________________________ Date of Birth ___________________ Grade Level: __________________________ Contact Information: Name of Person Completing Application: __________________________ Relationship to Student: __________________________ Phone Numbers: ________________________________________________ Home Work Cell Best Time to Call: ________________________________________________ Email Address: ____________________________________________ Address: ________________________________________________ Street Address ________________________________________________ City State Zip Code Emergency Contact Information: Name of Emergency Contact: __________________________ Relationship to Student: __________________________ Phone Numbers: ________________________________________________ Home Work Cell Email Address: ____________________________________________ Students Current School Information: School: ________________________________________________ School District: ________________________________________________ Teacher: ________________________________________________ Please list other schools applicant has attended (add more to the back or white space as needed): School___________________________________ Dates of Attendance ________________________Grades_________ School___________________________________ Dates of Attendance ________________________Grades_________ Describe the difficulties that this student has experienced while learning how to read and write. Several may apply; check as many as necessary. _____ Difficulty remembering words already introduced on sight (sight words) _____ Difficulty with letter sounds (phonics) _____ Difficulty reading with fluency or smoothly _____ Difficulty understanding what is read (comprehension) _____ Difficulty with spelling _____ Difficulty writing sentences Other: ________________________________________________________________________________ When did the difficulties with literacy skills first become apparent? __________________________ _________________________________________________________________________________ Please describe the students present reading/writing abilities. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Does the student have an IEP? Yes/No If yes, what is the focus of the educational plan? ______________________________________________ _____________________________________________________________________________________ What types of extra assistance has the school been able to provide? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What other clinical services (outside of school) or special instruction does your child receive? _____________________________________________________________________________________ _____________________________________________________________________________________ Does the student have any health problems? Yes/No If yes, please describe. __________________________________________________________________ _____________________________________________________________________________________ Does the student have any diagnosed vision problems? Yes/No If yes, please describe. __________________________________________________________________ _____________________________________________________________________________________ Does the student have any diagnosed hearing problems? Yes/No If yes, please describe. __________________________________________________________________ _____________________________________________________________________________________ How would you describe the students early language development? At approximately what age did the student begin to say words; 2-3 word phrases; sentences? _____________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Behavioral History: Does your child get along well with brothers and sisters? ___________________ Does he/she get along well with peers? _________________ Does he/she get along well with adults? _________________ Favorite adult ___________________ Have you observed that your child differs from others in the following ways? More sensitive Yes____ No____ More aggressive Yes____ No_____ More stubborn Yes____ No____ More withdrawn Yes_____ No____ More fearful Yes ____ No ____ More active Yes____ No____ Primary language spoken at home: _________________________________________________ Primary language used by this student for school work: _____________________________________ How much time does the student spend watching TV daily? ____________________________________ How much time does the student spend on the computer or other electronic devices daily? ____________ What sort or activities does the student engage in on these devices? ______________________________ _____________________________________________________________________________________ What activities does the student most enjoy, in or out of school? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What else would you like us to know about him or her? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Does anyone in the students family have a history of reading or writing difficulties? Yes/No If yes, please explain. ___________________________________________________________________ Parent/Guardians Name: ______________________________________Age: _____________________ Occupation: __________________________________________________________________________ Employer: ____________________________________________________________________________ Parent/Guardians Name: ______________________________________ Age: _____________________ Occupation: __________________________________________________________________________ Employer: ____________________________________________________________________________ Please list all household members currently living with the applicant: NameAgeRelationship to Applicant THANK YOU FOR BEING SO COMPLETE IN FILLING OUT THIS FORM Revised 10/16 Western Kentucky University Literacy Clinic Assessment and Photographic Permission and Release of Pupil Information I, ___________________________________________, give permission to the Western Kentucky (Name of Parent or Guardian) University Literacy Clinic to assess the literacy skills of _______________________________________. (Name of Student) I also give permission for the Western Kentucky University Literacy Clinic to release copies of confidential evaluation information completed on ___________________________________________ (Name of Student) to his/her school or to any other professional agency specified by me. The information may be released by mail, fax, conference, or telephone to/from the WKU Literacy Clinic. _____________ (please initial). I also hereby grant permission for my childs photographic image, video and audio recordings to appear in information published for the WKU College of Education. The purpose of the photography is to provide data and illustrations for WKU instructional and research programs. I understand the images and recordings may be used in professional conferences, journals, and publications. I understand that these images and recordings are the property of Western Kentucky University and may be used at the Universitys discretion without compensation to me or to my child. I waive all rights to inspect or approve the finished products that may be used in connection with this image. I have read this release and am fully familiar with its content. Signature: ______________________________________________________ Print Name: ______________________________________________________ Parent or Legal Guardian of: ____________________________________ Date: ______________________________________________________ PAGE 6 $ - > C O + N T V V f h u 4 Q R / 9 = E + 6 S n o ھޡ hQ 5h hV?K 5hrv hQ 0J j hQ Uh