Lose The Training Wheels™ Program



2019 SUMMER LEARNING ACADEMY APPLICATION

DATES

June 17, 2019 - July 18, 2019

Mondays – Thursdays (with the exception of 4th of July week, which will be Monday – Wednesday)

9:00 a.m. – 12:00 p.m.

LOCATIONS – check box to indicate location to which you are applying

CIRCLEVILLE

Circleville Elementary School

o Students who have completed grades 1 – 4

COLUMBUS

Bethel International United Methodist Church

Two classes: circle one to which you are applying

o Students who have completed grades 1 – 3

o Students who have completed grades 4 - 6

LANCASTER

Forest Rose School

o Students who have completed grades 1 - 4

MOUNT VERNON

New Hope Early Education Center

o Students who have completed grades 1 – 4

NEWARK

Flying Colors Public Preschool

o Students who have completed grades 1 - 4

ZANESVILLE

National Road Elementary School

o Students who have completed grades 1 - 4

Applications must be received by May 1, 2019. After April 15, registration will be open to students with other exceptionalities. The Summer Learning Academy is limited to a total of 8 participants, so you are encouraged to apply as soon as possible. Parents of applicants will be notified of admission status within three weeks of receipt of application.

Please note: submitting an application does not guarantee admission to the Summer Learning Academy.

ATTENDANCE POLICY

Since research indicates that attendance is an important factor of students’ success in academic summer programs, a commitment to attendance is mandatory for families applying to the Summer Learning Academy.

The parents of all applicants must agree that the student will attend for all five weeks and have no more than three unexcused tardies and three unexcused absences. Illness and family emergency are considered excused. Vacation is NOT considered an excused absence.

COST

The fee for the Summer Learning Academy is $150. Payment must be received with the application.

Families utilizing the DSACO Education Scholarship must submit the $150 fee with the application. At the conclusion of the Summer Learning Academy, upon meeting the attendance criteria (no more than three unexcused absences and three tardies), the family will be reimbursed.

If an applicant is not selected for admission, a full refund will be issued.

IEP AND GOALS

To provide individualized academic instruction, the Summer Learning Academy instructors will focus on addressing two IEP goals for each student. The goals, one literacy and one math, will be selected by the student’s parent. If the child is accepted to the Summer Learning Academy, parents must provide the student’s IEP to DSACO and submit in writing the two goals they have selected for the Summer Learning Academy staff to focus on. The IEP and notification of selected goals must be submitted to DSACO by May 5.

OTHER REQUIREMENTS

The DSACO Summer Learning Academies are designed to create an environment that maximizes student learning. Due to staffing limitations, we are unable to accept students who require one-on-one assistance during the school year for behavior and/or safety issues.

1. REQUIREMENTS for application to be considered:

• Student has completed 1st grade and not yet entered 5th grade Yes No

(for Columbus site only, completed 1st grade and not yet entered 7th grade)

• Student has Down syndrome Yes No

• Student will attend all five weeks Yes No

• Student will arrive at 9:00 am (not later) daily Yes No

• Student’s IEP will be provided to DSACO by May 5, 2019. Yes No

• Parents will select and notify DSACO of one IEP math goal and one IEP literacy goal for Summer Learning Academy focus by May 5, 2019 Yes No

• Student does not require one-on-one assistance at school for behavioral issues Yes No

2. Student Information:

|CHILD’S NAME | |NICKNAME (OPTIONAL) |      |

|PARENT/ | |

|GUARDIAN | |

|NAME(S) | |

|MAILING | |

|ADDRESS | |

|CITY | |STATE |      |ZIP | |

|MOM CELL |     |DAD CELL |     |

|DATE OF BIRTH |   |CURRENT GRADE LEVEL | |

|EMAIL ADDRESS | |

For all questions below, please feel free to use additional space if required.

| |

|3. Medical/Emotional Information: |

| |

|Is your child on any medications that we need to be aware of, or does your child use braces, hearing aids, communication devices, etc.? (Please note: we will |

|not be responsible for administering medications during the program.) |

|      |

|Please check the boxes to the left of any conditions that apply, and make remarks below. |

| |Low stamina | |Visual impairment | |Difficulty functioning in a social setting |

| |Oppositional behavior | |Incontinence/needs assistance with toileting| |Child is non-verbal and requires a |

| | | | | |(volunteer) fluent in sign |

| |Challenges with attention or focus (such as| |Resistance to being with strangers | |Other (please describe below) |

| |autistic tendencies, ADD or ADHD) | | | | |

| |

|Additional information about which we should be aware, including remarks about above conditions, food allergies, etc.: |

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|4. Behavior Information: |

|Please mark the appropriate box as it relates to the applicant. |

| |Always |Sometimes |Seldom |Never |N/A |

|Can communicate his/her needs | | | | | |

|Gets frustrated easily | | | | | |

|Can consistently make appropriate choices | | | | | |

|When upset can manage his/her emotions | | | | | |

|Consistently follows directions | | | | | |

|Cooperates with others | | | | | |

|What strategies/techniques are used at home or school to discourage inappropriate behavior and promote positive behaviors: |

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|Please share any additional information that will enable staff to work successfully with this applicant: |

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Please email application to jkemper@ or print and mail applications to:

Julie Kemper, Program Coordinator of Educational Services

DSACO

510 East North Broadway

Columbus Ohio, 43214

Applications must be received by May 1th to be considered.

We reserve the right to dismiss any student at any time throughout the five-week program. Please know we will do our best to problem-solve and dismissal will be used only as a last resort.

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