D-CAP : Student Application

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Dub-C Autism Program Student Application

Personal Information

Please make sure you have filled in all required fields with valid information.

First Name:

Last Name:

RamNet ID:

Birthdate:

Phone:

- Phone (next 3 digits) - Phone (next 4 digits)

WCU Email:

Term to begin D-CAP supports (ex. Fall 2023):

Do you or will you live on campus?

Yes No

Residence Hall:

Room Number:

Do you have a roommate?

Yes No

Permanent/Home Address:

City:

State:

Zip Code:

Are you registered with OVR?

Yes No

Case Counselor Name:

D-CAP funding is available through OVR. Please apply to OVR within 14 days of submitting your D-CAP application.

Educational Information

Please make sure you have filled in all required fields with valid information.

High School Information

Name of High School:

What year did you graduate High School?

I took the following test:

ACT SAT None

Score on Test:

Did you need extra time?

Yes No

Other accommodations for test:

Other:

Structure of your classes in High School:

10 or less students in class
11-20 students in class
Over 20 students in class

General Education
Resource Room
Individual Instruction
Learning Support
Social Skills/Strategies

Other:

Favorite Teacher/Staff Member to work with in High School (if applicable):

What types of activities did you work on together?

Why was this person easy to work with; what were the qualities of this person that made working with this person easier.

College Information

Colleges prior to West Chester (leave blank if not applicable):

Name of College 1:

Area of Study 1:

Name of College 2:

Area of Study 2:

Why did you transfer to WCU?

West Chester University

What year are you based on credits?

What college are you enrolled in at WCU?

Who is your academic advisor at WCU?

What is your major at WCU?

Why did you choose this major?

Dream Job Details

What is your dream job?

Why is this your dream job? / What excites you about your dream job?

How would you explain your learning style (i.e. how do you learn best)?

Visual
Auditory
Visual and Auditory
Sit in Front in Class
Sit Anywhere in Class
Quiet Environment

Can Learn in Distracting Environments
Like Things to be Explicit
Other

Other:

Work Experience

Please make sure you have filled in all required fields with valid information.

Have you ever been employed/worked a paying job?

Yes No

Where were you employed?

What were your duties at your job?

What skills did you develop?

Have you ever done volunteer work?

Yes No

Where did you volunteer?

What were your duties when you volunteered?

What skills did you develop?

Parents/Family Information

Please make sure you have filled in all required fields with valid information.

Please provide information for Parents/Guardians and Siblings for which we have permission to contact.

First Name 1:

Last Name 1:

Relation 1:

Phone 1:
- -

Email 1:

First Name 2:

Last Name 2:

Relation 2:

Phone 2:
- -

Email 2:

First Name 3:

Last Name 3:

Relation 3:

Phone 3:
- -

Email 3:

First Name 4:

Last Name 4:

Relation 4:

Phone 4:
- -

Email 4:

Housing/Living

Please make sure you have filled in all required fields with valid information.

Current Living Arrangements:

Living in Dorm Alone
Living in Dorm with Roommate
Living in Apartment Alone

Living in Apartment with Roommate(s)
Living with Parents/Guardians (own room)
Other

Other:

Describe your living habits

Cleanliness:

Clean
Have clean areas
Need to dust/vaccuum/wash

Neatness/Organization:

All things have a place
Some things have a place
Nothing has a place to go

Volume:

Quiet
Normal volume
Loud

Schedule:

Have a schedule for chores/housekeeping
Have a schedule for some
No schedule for chores/housekeeping

Company:

Like a majority of time to be private/alone
Like 50% of the time to be private/alone
Prefer to be around others in house/living arrangement

Transportation

Do you have a driver's license?

Yes No

Do you/have you used public transportation? (buses/cabs/uber/subway)

Yes No

Stress

Other:

How do you respond when you are very afraid?

What are you coping strategies when you are very afraid?

How do you respond when you are very anxious?

What are your coping strategies when you are very anxious?

How do you respond when you are very frustrated?

What are your coping strategies when you are very frustrated?

Social Interactions

Other: