REGIONAL TEACHING AND SUPPORT SERVICES APPLICATION
FORM
V A N
A S C H
If you wish to apply to access NZSL@School, please also complete the attached NZSL@School
Application
on
page 3.
DEAF
E D UC A TI O N C E N TR E
S I N C E
Date:
Child/Young Person’s Name:
D.O.B.:
1 8 8 0
VAN ASCH
DEAF
Current Year Level:
EDUCATION CENTRE
Please attach current IEP/IDP
AUDIOMETRY: Frequency (Hertz)
Please attach 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
125
50
Application declined
decibels Hearing Level
70
Reviewable
800
40
Only children with a diagnosed hearing loss will be considered for
admission to the Resource Teacher of the Deaf caseloads.
No application made
4000
30
60
High
2000
20
Hearing Loss
Application in progress
1000
0
1
2
5
Audiological:
Include a full audiological report and complete the audiogram.
Very High
500
10
and Literacy assessment
ORRS Status
250
-10
1
0
80
90
100
110
120
130
High Health
Identifies as:
Maori
Pacific Islander
New Immigrant Yes
No
NZ/European
Asian
Other
: Year of arrival:
Hearing Aids:
Cochlear Implant
Aided audiogram attached with details of hearing aids and assistive equipment used
Use of amplification:
Inconsistent
Current Resource Personnel:
ORRS funded Teacher Aide:
ESW
SLT
hours / week
hours / week
Consistent
ORRS funded specialist teacher (0.1/0.2)
SEG Teacher Aide
DRP
hours / week
hours / week
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)
1
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: __________________
Name of Parent/s / Caregiver/s: ___________
Email: ________________________ _
________________________________________
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.
3 if
appropriate
• 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:__________
2
NZSL@School Application
NB: Please refer to the NZSL@School Guidelines for information about access to NZSL@School at
http://online.vanasch.school.nz/WebSpace/591/
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)
o NZSL
o Spoken Language
 English
 Te Reo
 Other (specify) __________
Expressive Language (at school)
o NZSL
o Spoken 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.
o NZSL
o English
o Te Reo Māori
o Other (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 their learning and
communication with the teacher/peers.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3
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 of submitting this application for
NZSL@School, it is sufficient for parent/caregiver only to sign this application form.
4