Application Deadline
Extended until
November 15, 2001

Please print and mail completed form to:

Executive Director
The Arc of Kentucky
833 East Main Street
Frankfort, KY 40601

The person you receive this application from may assist you in completing it, if you need assistance. For additional information or assistance from The Arc, please feel free to contact Patty Dempsey at The Arc
office 1-800-281-1272 or 502-875-5225 or email arcofky@aol.com

This program is funded by the Kentucky Developmental Disabilities Council

Developmental Disabilities Definition
Section 102(8) of the Developmental Disability Assistance and Bill of Rights P.L. 102-230 defines the term "developmental disability" as a severe, chronic disability of a person 5 years of age or older which:

A) is attributable to a physical or mental impairment or a combination of a physical and mental impairment;
B) is manifested before the person attains the age of twenty-two;
C) is likely to continue indefinitely;
D) results in substantial limitations in three or more major life activities:

self-care,
receptive and/or expressive language,
learning,
mobility,
self-direction,
capacity for independent living, and
economic self-sufficiency.

E) reflects the person's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services which are lifelong or extended duration and an individually planned and coordinated, except that such term when applied to infant and young children means individuals from birth until five years of age, inclusive, who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in a developmental disability if services were not provided.

*Source: Developmental Disabilities Assistance and Bill of Rights Act of 1990 (PL 101.496).

1. Name of Applicant


(Applicant must be biological or adoptive parent and have legal authority to
represent child in I.E.P. process)
Relationship to Student
Male Female Single Married Divorced
Primary Language
Address
Address
County
City
 State Zip
Daytime Telephone
 Evening Telephone
Fax
Email
Congressional District

2. Name of Additional individual authorized to participate in I.E.P. process

 

Secondary Name

I agree to the pursuit of inclusion for (student's name)

Relationship to Student
Male Female Single Married Divorced
Primary Language
Address
Address
County
City
 State Zip
Daytime Telephone
 Evening Telephone
Fax
Email
Congressional District

3. Why are you interested in participating in the Access to Better Choices?

4. What the specific concerns, goals, issues or problems that encourage you to apply for this project?

5. Will you make a commitment to attend all of each of the three (3) training sessions? Statewide training sessions will be held January 5-6, 2002 and January 12-13, 2002 at the Holiday Inn in Frankfort. Regional training sessions will be held in early 2002. Failure to attend both statewide sessions will result in being dropped from the project.

Yes No

6. Are there specific accommodations needed for you to participate in this project?

Yes No

If yes, please describe:


STUDENT INFORMATION

1. Name
2. Date of Birth Male Female
3. Ethnic Heritage

4. Describe your child's disability and how it affects his or her ability to function in at least three (3) areas of major life activities as described in the Developmental Disabilities Definition at the top of this page.

5. How much time of the school day does your student spend:

With Students
With Disabilities?		 With Students
Without Disabilities?
(a) Classroom
(b) Extracurricular
(c) Lunchroom
(d) Recess
(e) Transportation
(f) Music
(g) Art
(h) Physical Education

6. What does your student's current I.E.P. state in regard to the identified disability or disabilities (list all)?

7. Describe the severity or your student's disability.

8. What school district does your student attend?

9. What school does your student attend?

10. Please include a copy of your student's I.E.P.

11. Please list services currently receiving outside of school such as recreation, respite care, etc.

Please print and mail to the address at the top of the page.

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