MESA Request Form

The University of Iowa
Regional Autism Services Program
Child Health Specialty Clinic

Request Form

Experience Story Kit Application

Offer valid February through May 2000

Application Date:
Name:
Address:
City:
State:
Zip:
Phone:
E-mail:
Birthdate of Child:
Sex:
Is your son/daughter receiving:	Special Education programming this summer
	Extended School Year Services this summer
	Waiver Services including:

Please rate the following: (you will also rate these after completing your books, too)

This best describes how my child independently attends/reads traditional books:

Very little interest
Some interest
Can read some books by himself

My plan for a story to address new language or a new behavioral routine:

I will need to call you for support
I have ideas to discuss with you
I am ready!

Choose the durability of the pages in the book you prefer:

Paper pages with sheet protectors
Stiffer (almost non-destructible) pages with strong plastic within the page protectors

Sharing the Results:

I will agree to share results (changes in behavior, new language skill growth, increased independence in reading, etc.) through:

Phone discussion
Written evaluation
Potential of sharing our experience stories and what improvements we’ve seen at a conference