Reading Clinic

Application

Print this and fill it out.  Thank you for your interest in the Towson University Reading Clinic.   Please answer each question as thoroughly and completely as possible.   If you have any questions, please call

(410) 704-2558.   Send the completed application to:       Dr. Elizabeth Dicembre

                                                                                             Towson University/RSET

                                                                                             8000 York Road

Date:   _____________                                        Towson, MD   21252

Student:   _______________________________________________________________________

Date of Birth:   ___________________________        School Grade:   _______________________

Child's School:   __________________________________________________________________

Parent(s)/Guardian(s) Name:   ______________________________________________________

Phone Numbers:   Day   _____________________      Evening    ______________________________

Address:   _______________________________________________________________________

                            Number                  Street                           City                      State                    Zip Code

E-Mail Address:   _______________________________________________________________

Has your child ever attended Reading Clinic before?   __________   If so, when?   __________

Questions:

•  Why do you want to bring your child to the Reading Clinic?   How do you think we can

help?

•  How is your child doing in school?   In reading?   In math?   In other subjects?

•  Has your child had any education evaluations?   By whom?   When?

(Please bring a copy of previous evaluations to the first clinic meeting.)

4)    Is your child currently receiving academic assistance (such as tutoring or special education)

      in school or with another agency?

•  Has your child ever been retained?   ____________   What grade(s)? ____________________

6)   How does your child interact with other children at school, in the neighborhood, and with

      teachers?

•  As an infant or young child, were there any concerns about your child's development

      (language, motor skills, lead poisoning, etc.) ?

•  Does your child have any chronic health concerns (such as ADD/ADHD, allergies, asthma, epilepsy, diabetes, etc. )?

•  Is your child currently taking any medication(s)?   Will the medication(s) affect the child's

      performance during the Reading Clinic session?

•  Has your child's vision been tested?   When?   Does the child wear glasses?

•  Has your child's hearing been tested?   When?   Results?

•  Has your child's speech been tested?   When?   Results?   Has your child ever received

      speech therapy?

•  What adult(s) live with the child (e.g. mother, stepfather) ?   Their age, occupation, and highest level of education

•    Is English the usual language spoken at home?   Other languages?

•  What are your child's interests?   What does your child do well?

•  Is there anything else we should know, including any special concerns that you have about

      your child?

•  Reading Clinic is on Tuesday and Thursday evenings.   Which day would you prefer?

_____________________________

•  Reading Clinic is on weekday evenings.   Which session would you prefer?

         __________   5:00 p.m.--6:00 p.m.    __________   6:00 p.m.--7:00 p.m.   __________ either

18) I give my permission for the Towson University Reading Clinic to use the information          provided on this questionnaire and during clinic to assist in identifying my child's                 educational needs.   I understand that this information and any other evaluation                    information may be used for teaching and/or research purposes.   All of the information        will be strictly confidential.

       ________________________________________                          _________________

                        Signature of Parent/Guardian                                               Date

19) If you would like us to contact your child's teacher, please fill out the information below:

      Child's Reading Teacher:   _____________________   School Phone Number:   ___________

       I give my permission for the Towson University Reading Clinic to discuss my child's             progress with his/her teacher(s) or counselors.

      ________________________________________                           _________________

                    Signature of Parent/Guardian                                                Date

•  Also, I give my permission for my picture or my child's picture to be used in marketing materials (e.g. brochure, web page) for the Towson University Reading/Literacy Clinic.

      ________________________________________                           __________________

                       Signature of Parent/Guardian                                               Date