Alternate Format Materials Application

Name of Student:___________________________  Date of Birth:______________________

Grade/Level__________________   School________________________________________

School Address______________________________________________________________

District ____________________________________________________________________

To be completed by a teacher who has a Masters Degree in Learning Disabilities, a Guidance Counselor or an Educational Psychologist

Verification:

The results of a comprehensive assessment indicate that

_____________________________________________ (student's name)

has a specific learning disability which results in a print handicap.

______________________________     _______________________________
Name [please print]                                    Title

______________________________       _______________________________
Signature                                                     Date

To be completed by the School Administrator/Designate:

Please indicate the statements which apply to the above named student:

• has an Individual Support Services Plan which indicates the levels of support required across the Pathways     _____Yes      _____No

• is receiving instruction in strategies to compensate for the specific Learning Disability _____Yes      _____No

• a decision-making process ( See Using Technology to Enhance Student's Differing Abilities ) was followed by the ISSP team to determine that this alternate format is an appropriate choice for this student at this time    _____Yes      _____No

________________________    _________________     ________________________
Signature                                       Title                                Date         

Does the student have access to a four-track tape-recorder*    Yes____  No____

This request is: for the student's present grade for the forthcoming year/grade

[Note: Requests for September `99, should be submitted by January 1, `99]

Name of text/novel_________________________________________________________

Year of Publication__________________ Edition____________________

ISBN# ___________________________  Author(s) _____________________________

_________________________________  Publisher______________________________

_________________________________  Date Required __________________________

Name and address of the person to whom the materials will be shipped:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Name, Address and Phone Number of the person who will be responsible for returning the materials to the Division of Support Services, Department of Education, P.O. Box 8700, St. John's, NF A1B 4J6 by June 15.

__________________________________________

__________________________________________

__________________________________________

_______________________________    ____________________     ________________
Signature of Person Making Request    Title                                     Phone Number

• A four-track recorder may be required to use some of the audiotapes. If your school does not have a four-track tape recorder, you can purchase one through the following.

Recordings for the Blind and Dyslexic (RFB&D)

20 Roszel Road

Princeton, NJ, USA

Phone 1-800-221-4792

Fax 1-609-987-8116 American Printing House for the Blind, Inc.

1839 Frankfort Avenue

P.O. Box 6085

Louisville, Kentucky 40206-0085

e-mail: info@aph.org

Phone:1-800-223-1839

Fax: 502-889-2274

Netsite: http://www.aph.org First 'C' entry