Inquiry Form : Defiance College

Address *

City *

State *

Zip/Postal Code *

County

Country *

First Name *

Preferred First Name

Last Name *

Address Line 1 *

Address Line 2 *

Zip/Postal Code *

Primary Phone *

Primary Phone Country Code

By checking this box, I agree to receive text and voice messages at the phone number I provide above. I understand that message frequency may vary, but I can expect approximately 4–6 messages per month. Message and data rates may apply. Reply STOP to opt out. You can read our full Opt-In Policy here.

Email *

Date of Birth *

Sex *

Entry Year *

Let us know the year you would start the program.

Student Type *

Entry Term *

Major *

Have you ever had a job where you earned a paycheck? *

Have you ever done any volunteer work? *

Have you taken any college classes before? *

Have you ever had a substance abuse problem (e.g., addiction or abuse of drugs or alcohol)? *

What are some of your strengths? *

How do you learn best? What is the best way for someone to teach you something new? *

What are some things that are difficult for you? *

Have you completed and submitted your application for Defiance College? *

Please use the space below to write any additional information that you think is important for us to know about you:

Applicant Performance Ratings Please complete this questionnaire by selecting the performance level (PL) that you think best describes your current skill level and ability for each of the items. We will use this information to learn more about you as an individual. This section should be completed by the applicant without input from other individuals.

PL-0 No Participation: You refuse to participate in the learning opportunity. This means that you choose not to try to do an activity.

PL-1 Early Instruction: You need prompts for most, or every, step in the task. This means that you need direct 1:1 assistance to complete the task. This means that you need someone to help you with every step of the activity.

PL-2 Guided Practice: You need specific prompts (e.g., verbal, written, gestural) to complete the task, but you do not need prompting for each step in the sequence. This means that you need help with the activity, but that you can do some parts of it on your own.

PL-3 Guided Independence: You need general prompts to complete the task (e.g., a reminder that it is an expectation to complete the task) or you complete the task within the structure of a program (e.g., because that is part of your routine at school). This means that when someone reminds you to do the activity or if it is a part of your routine you do it without any other help.

PL-4 Independent: You do not require additional instructions, prompting, or other assistance to complete the task. You independently seek resources as needed. This means that you do this activity without anyone reminding you or putting it in your schedule.

N/A: You have never had the opportunity to try this. This means that you have never been able to try the activity.

Rating: Accepting feedback or correction from others in an appropriate way. *

Rating: Advocating for myself if a need is not being met or if I need assistance *

Rating: Asking authority figures for clarification or help when I don’t understand something. Examples of authority figures are professors and supervisors *

Rating: Asking my peers for clarification when I am unsure what they mean *

Rating: Asking people in the community, who I don’t know, for assistance. Examples of people in the community are servers at restaurants and cashiers at the store *

Rating: Attending medical and mental health appointments *

Rating: Doing laundry *

Rating: Finding resources in the community by using the internet *

Rating: General upkeep of living space. General upkeep includes washing dishes, wiping down counters, vacuuming, mopping, cleaning the bathroom, and taking out the garbage *

Rating: Identifying and taking appropriate over the counter medications for minor ailments. Examples of minor ailments include headache, congestion, and heartburn *

Rating: Maintaining good personal hygiene. Examples of good personal hygiene practices are brushing your teeth daily, showering regularly, washing your hands after using the bathroom, and wearing clean clothes *

Rating: Making a simple meal (examples: canned soup, sandwich, frozen pizza, salad) *

Rating: Managing your time to balance non-preferred and preferred tasks. For example, ensuring that you turn your xbox off by 8:00 pm so you can study for an upcoming exam *

Rating: Organizing your living space so you can easily find things *

Rating: Scheduling medical and mental appointments. Examples of medical appointments are check-ups with the doctor, dentist appointments, or an appointment with your psychologist/psychiatrist *

Rating: Taking regular medications. Regular medications are medications that you take every day *

Rating: Telling a peer that something is bothering me without becoming verbally or physically aggressive *

Rating: Treating minor injuries at home. Examples of treating minor injuries include scrapes, first degree burns, splinters, and insect bites *

Rating: Understanding who to share personal information with and who not to *

Rating: Using Technology to connect with classmates and friends. Examples would be texting, twitter, and instagram *

Rating: Waking up on time and getting ready for the day *

What are the academic and career goals that you hope to accomplish at Defiance College? *

What are the life skills goals that you hope to accomplish at Defiance College? *

What are the interpersonal and recreational goals that you hope to accomplish at Defiance College? *

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Defiance College ASD Affinity Program Application

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