Student Services & Special Education

Peer Model Application
Early Childhood Special Education Program

A fee of $11 per day will be assessed for all Peer Model Students
(FEE SUBJECT TO CHANGE)

A Peer Model Student is expected to demonstrate age appropriate skills in the areas of play, social, behavior, speech, language and motor. Peer Model Students will provide positive peer interactions; demonstrate play skills and model appropriate language and behavior for children with special needs while in the classroom setting.

This form can be completed online or printed out.

Returning Peer applications must be received in the Early Childhood office no later than December 14th, 2007. Any returning peer application received after December 14, 2007 will be considered a first time peer and will be placed in the lottery system. Applications for new peers will be received starting January 1, 2008. Mid February 2008 selection letters and waiting list letters will be sent to all families. If there are any questions please feel free to call the Early Childhood office at 239-4400.

Program Information

Download: Peer Model Program Information (PDF: 21kb/1pg)

Print Version

Download: Peer Model Application (PDF: 19kb/4pg)

Mail to:
Early Childhood Special Education Program
11600 Knox Overland Park, Kansas 66210-3608
Phone: (913) 239-4400
Questions? Email: Julie Hunter or Joan Robbins

Online Version
Child Information
Full Name *
Date of Birth *
Age *
Sex *	Female Male
Address *

City *
State *		Zip Code *
Home Number *	( ) -
Name of Preschool currently attending

Length of time at this Preschool


Neighborhood Placement
Peer Models are placed in your neighborhood school whenever possible.

If your neighborhood school is not available would you be interested in attending a different Early Childhood location? *
	Yes	No

If indicated yes please check the schools you would be willing to attend.
Blue River Cottonwood Point Heartland Leawood Morse Prairie Star Stilwell		Cedar Hills Harmony Indian Valley Liberty View Oak Hill Stanley Sunrise Point

Program Preference
Please check the appropriate box if you have a preference of a 4-Day or 2-Day program. (No Guarantee)

Program *
2-Day Program Tuesdays & Thursdays Only at Indian Valley Elementary Location
2-Day Monday & Wednesday Only at Stanley Elementary Location
2-Day Tuesday & Thursday Only at Stanley Elementary Location
4-Day Program Monday - Thursday At all schools except Lakewood, Mission Trail, Overland Trail, Sunset Ridge and Valley Park

Time of Day *	AM PM Either

Peer Model Questionnaire
Peer Model Students should be able to appropriately interact with students with disabilities, other peer model students and adults in the classroom.

Please read each question and select the answer that best describes your child.

1. My child speaks English fluently throughout the day with children and adults. *
	Yes	Sometimes	Not Yet

2. My child is toilet trained. * Parents important note about toilet training: All Peer Models must be toilet-trained. Please note that Peers who demonstrate that they are not toilet-trained may be asked to leave the program.
	Yes	Sometimes	Not Yet

3. Is your child receiving any type of services thru Blue Valley School District or an outside agency? Ex: speech therapy *


4. Has your child been screened or evaluated for special education services? *
	Yes	No
	5. If yes, where and date of services?


6. What language(s) are spoken at home. *


7. Why do you think your child would be a good peer model? *


Parent Information
Full Name *
Email Address *
Home Number *	( ) -
Place of Employment *

Work Number *	( ) -

Additional Parent Information
Full Name
Email Address
Home Number	( ) -
Place of Employment

Work Number	( ) -

Sibling Information
Full Name
Age
Grade
School

Additional Sibling Information
Full Name
Age
Grade
School

Additional Sibling Information
Full Name
Age
Grade
School

Additional Information or Comments