Application for iDevice

Date:

This request is for a child enrolled in the following program(s):

Rehabilitation Centre for Children

Employment & Income Assistance

Children’s disABILITY Services

Community Living disABILITY Services

Child & Family Services

None of the above services

Name of Community Service Worker (if applicable)

Phone Number of Community Service Worker:

Child/Youth Information

First Name

Middle Initial

Last Name

Gender

Date of birth

Diagnosis

Mailing address

PHIN (9 digits on Manitoba Health Card)

School

Preschool

Daycare

Grade

Other Program Name

Language(s) spoken at school

Language(s) spoken in the home

Parent/Guardian Information

First Name

Last Name

Home Phone

Cell Phone

Work Phone

Relationship

Mailing address

Parent/Guardian Information

First Name

Last Name

Home Phone

Cell Phone

Work Phone

Relationship

Mailing address

Applicant Information

Name

Employer

Discipline

Cell Phone

Work Phone

Mailing address

Additional Clinician/Support Staff Information (SLP, OT, PT, Resource Teacher)

Name

Employer

Discipline

Phone

Name

Employer

Discipline

Phone

Responsibility: (Who will be responsible for maintaining/updating the device)

Name

Relationship

Contact Phone (if not already listed)

Contact Email (if not already listed)

Level of iOS knowledge

Hearing

Not Impaired

Impaired

Impact of hearing on selection of SGD

Vision

Describe any visual problems:

Date and results of last visual exam

Does this child wear glasses? Please comment on corrected vision if possible:

If possible identify target size, type (photos, symbols), spacing, total number:

Impact of vision impairment on selection of communication device:

Current Access

Points with finger

Selects with hand/fist

Direct Selection with an aid (ie. Stylus)

Scanning - if checked please describe, including placement of switch (partner assisted, auto scan, step scan)

Eye Gaze

Other

Current Communication Skills – Expressive Language

Behaviour (e.g. crying, aggression, self-injury)

Gestures (ie. head nod/shake, wave, point, reach push away, give)

Other: (describe)

Please comment on child’s literacy skills (exposure to and interest in written language, sight words, etc.)

Please describe any previously introduced augmentative communication systems (ie. light tech) and their outcomes:

Describe the experience/exposure the child has had with computers or technology in general:

Implementation Plan:

iDevice Package Requested

Is this a replacement device?

YesNo

If yes – do you have an iCloud backup to be restored on the new device?

YesNo

*Please note all new devices will be automatically set up with our remote management system unless an iCloud backup is available*

iPad Mini (8.3” display)

iPad (10.9” display)

iPad Pro (12.9” display)

Funding Source (Please only check one if you know who the funder will be)

Children’s Rehabilitation Foundation

Child and Family Services

Jordan’s Principle – *OARC will supply you with a quote for you to submit to Jordan’s Principle*

Variety – *OARC will supply you with a quote for Set Up & Training for you to submit to Variety*

Other – Please indicate

Letter of Support

All applications must be submitted with a letter of support written by the child’s current speech-language pathologist. Additional letters from family and other clinicians are encouraged. Please click on Upload File to attach your letter(s):

Upload File

Max file size 10MB.

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Additional Signature Pages Get the signature pages by clicking here

There are three additional pages that require signatures from parents/legal guardians and the applicant/speech-language pathologist. Please click on Upload File to attach your additional pages once they have been signed.

Upload File

Max file size 10MB.

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**Please ensure you have included your letter of support and the additional signature pages**

Thank you! Please contact us at mary-alex@oarc.ca if you've had any dificulty of have any questions.

Application For A Communication Device

This request is for a child enrolled in the following program(s):

Name of Community Service Worker (if applicable)

Phone Number of Community Service Worker:

Child/Youth Information

Parent/Guardian Information

Parent/Guardian Information

Applicant Information

Additional Clinician/Support Staff Information (SLP, OT, PT, Resource Teacher)

Responsibility: (Who will be responsible for maintaining/updating the device)

Hearing

Vision

Mobility

Current Access

Current Communication Skills – Receptive Language
_{we acknowledge there are no prerequisites for AAC and this is for information only}

Current Communication Skills – Expressive Language

Please comment on child’s literacy skills (exposure to and interest in written language, sight words, etc.)

Please describe any previously introduced augmentative communication systems (ie. light tech) and their outcomes:

Describe the experience/exposure the child has had with computers or technology in general:

Implementation Plan:

iDevice Package Requested

Apps / Software:

Case:

Funding Source (Please only check one if you know who the funder will be)

Application For A Communication Device

This request is for a child enrolled in the following program(s):

Name of Community Service Worker (if applicable)

Phone Number of Community Service Worker:

Child/Youth Information

Parent/Guardian Information

Parent/Guardian Information

Applicant Information

Additional Clinician/Support Staff Information (SLP, OT, PT, Resource Teacher)

Responsibility: (Who will be responsible for maintaining/updating the device)

Hearing

Vision

Mobility

Current Access

Current Communication Skills – Receptive Language *we acknowledge there are no prerequisites for AAC and this is for information only*

Current Communication Skills – Expressive Language

Please comment on child’s literacy skills (exposure to and interest in written language, sight words, etc.)

Please describe any previously introduced augmentative communication systems (ie. light tech) and their outcomes:

Describe the experience/exposure the child has had with computers or technology in general:

Implementation Plan:

iDevice Package Requested

Apps / Software:

Case:

Funding Source (Please only check one if you know who the funder will be)

Current Communication Skills – Receptive Language
_{we acknowledge there are no prerequisites for AAC and this is for information only}