EduCare Application

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For consideration into Arkansas State University’s EduCare program, please complete the following tasks and provide all documentation listed by August 19, 2021 Blank responses or missing documentation cannot be considered. Please contact us with any questions or concerns. All applications will be stored on a secure database and personal identifying information will only be viewed to determine acceptance into the EduCare program.

1. GENERAL INFORMATION

Name*

First Name

Last Name

Date of Birth*

Age*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Gender*

Male Female Other

How do you identify yourself?*

Hispanic/Latino American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White

Other:

Please check box below that best represents the level of support required by the applicant*

A. Student is independent and requires no support B. Student requires moderate-low support C. Student requires maximal support

If you checked option B or C, please give a brief explanation of the current supports that the applicant has/needs. *

Please list any medical conditions or health concerns that we need to know about for the applicant to safely participate in this program.

2. FAMILY/CAREGIVER CONTACT INFORMATION

Family/caregiver name: *

First Name

Last Name

Family/caregiver address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Family/caregiver phone:*

Family/caregiver email address:*

5. Additional Information

We would like to ask a couple of questions to learn more about you. Please answer the following questions to your best ability. If you are not comfortable answering a question, please respond with “n/a”. Blank answers/applications will not be considered.

What is/are the name(s) of your disability/disabilities? *

N/A

What is your preference on language regarding autism?*

Identity-first language (i.e. autistic individual) Person-first language (i.e. individual with autism) I don’t have a preference I am not sure

Other:


	1A little bit	2A fair amount/sometimes	3Most of the time	N/A
How would you say autism and/or other diagnoses affect you academically?	: How would you say autism and/or other diagnoses affect you academically? (1A little bit)	How would you say autism and/or other diagnoses affect you academically? (2A fair amount/sometimes)	How would you say autism and/or other diagnoses affect you academically? (3Most of the time)	How would you say autism and/or other diagnoses affect you academically? (N/A)
How often would you say autism affects you socially?	How often would you say autism affects you socially? (1A little bit)	How often would you say autism affects you socially? (2A fair amount/sometimes)	How often would you say autism affects you socially? (3Most of the time)	How often would you say autism affects you socially? (N/A)
How often would you say autism affects you in communicating with others?	How often would you say autism affects you in communicating with others? (1A little bit)	How often would you say autism affects you in communicating with others? (2A fair amount/sometimes)	How often would you say autism affects you in communicating with others? (3Most of the time)	How often would you say autism affects you in communicating with others? (N/A)
How often would you say autism affects taking care of yourself or living independently?	How often would you say autism affects taking care of yourself or living independently? (1A little bit)	How often would you say autism affects taking care of yourself or living independently? (2A fair amount/sometimes)	How often would you say autism affects taking care of yourself or living independently? (3Most of the time)	How often would you say autism affects taking care of yourself or living independently? (N/A)
How much assistance do you need with personal care including bathing, brushing teeth, trimming facial hair, etc.	How much assistance do you need with personal care including bathing, brushing teeth, trimming facial hair, etc. (1A little bit)	How much assistance do you need with personal care including bathing, brushing teeth, trimming facial hair, etc. (2A fair amount/sometimes)	How much assistance do you need with personal care including bathing, brushing teeth, trimming facial hair, etc. (3Most of the time)	How much assistance do you need with personal care including bathing, brushing teeth, trimming facial hair, etc. (N/A)

Check all that apply*

I get dressed by myself I know what type of clothing to choose when it is cold/hot outside I brush my teeth 1-2 times a day I brush and style my hair by myself I take a shower by myself without reminders I use deodorant I wash my hands every time I use the restroom (for females) I manage my menstrual care by myself

What college courses and subjects interest you?

Where would you like to live in the future? With whom?

What careers/jobs interest you?

7. REFERENCES

List your references here

Name

First Name

Last Name

Phone

Relation to applicant

Name

First Name

Last Name

Phone

Relation to applicant

Name

First Name

Last Name

Phone

Relation to applicant

APPLICATION CHECKLIST

Fill out the application form above. Blank responses on the form will not be considered for the program List of two non-family references that know the applicant and can attest to their abilities/strengths/weaknesses in regard to education or work. Reference letters are encouraged but not required. See section 7 FERPA Form (Family Education Rights & Privacy Act of 1974) completed and submitted (mail or fax) to the Office of the Registrar (Contact Information Provided on FERPA Form).

1. GENERAL INFORMATION

2. FAMILY/CAREGIVER CONTACT INFORMATION

3. APPLICANT'S EDUCATION HISTORY

4. WORK HISTORY

5. Additional Information

6. COMMUNITY SAFETY/TRANSPORTATION

7. REFERENCES