OPPORTUNITY FOR 3-YEAR OLDS
TO BE PRESCHOOL ROLE MODELS
The Early Childhood Special Education program in Portsmouth Public Schools is seeking 3 year-olds to participate
in self-contained Early Childhood Special Education classes as “Reverse Inclusion” students. Applications will be
accepted through Friday, April 17, 2015, for the programs located in one of our four public preschool centers.
WHAT IS REVERSE INCLUSION?
Reverse Inclusion is the practice of placing typically-developing students into an Early Childhood Special
Education class on a voluntary basis to serve as social and educational role models for students with disabilities.
WHAT DOES MY CHILD GAIN FROM BEING A ROLE MODEL?
free enrollment in a quality preschool.
o Learning activities are aligned with state standards (Virginia Foundation Blocks for Early Learning).
o Instruction is provided in an environment with a staff-student ratio of less than 1:8.
the opportunity to learn more realistic and accurate views about individuals with disabilities.
the opportunity to develop positive attitudes toward others who are different from themselves.
models of individuals who successfully achieve despite challenges.
HOW ARE THE STUDENTS SELECTED?
Applications for the 2015-2016 SY will be accepted until April 17, 2015. Once applications are received,
parents will be contacted to set up a screening and observation for their child to insure that the children selected
will serve as strong peer role models (demonstrating well-developed language skills, independence in self-care
[feeding, dressing, toileting], the ability to initiate play and conversation with other children, and the capacity to
follow classroom routines with minimal prompting). Children of Portsmouth Public Schools employees may apply
for the program but would be required to provide their own transportation if they live outside the city of
Portsmouth.
WHO SHOULD APPLY?
Parents of students who are:
age 3 by June 30, 2015 but 4 after October 1, 2015
able to attend a half-day preschool five days per week (AM or PM session) for the entire 2015-2016 SY.
WHAT IS THE COST?
There is no cost for this program.
WHAT IS EXPECTED?
Students participating in the program are expected to:
pass a skills screening conducted by appointment at the Office of Special Education
participate in one half day session as part of the screening process
enroll at the Office of Special Education upon acceptance into the program
arrive at school and be picked up on time and have good attendance
be a positive role model for other students in the class
participate in all class activities & abide by all school policies
HOW DO I APPLY?
Applications can be obtained from and returned to the: Office of Special Education at SH Clarke Academy,
2801 Turnpike Road, Portsmouth, VA 23707, (Attention: Lisa Gehring, Program Specialist/ECSE Program
Phone: (757) 393-8471)
Provide supporting documentation including:
o the child’s state-certified birth certificate, up-to-date immunization record, copy of a current physical
proof of residence (not required for PPS employees)
Screenings and observations will be scheduled by appointment April-June 2015. Candidates will be notified
of selection decisions by the end of June 2015 and the “Reverse Inclusion” students will begin school in
September 2015.
STUDENT APPLICATION
ROLE MODEL POSITION IN REVERSE-INCLUSION PROGRAM
Student Information
Child’s Name
Birthdate
Race/Ethnicity
Gender
Hispanic Yes or No?
Preschool Zone (TBD by Office of Special Education)
Parent’s / Guardian’s Name
Parent’s / Guardian’s Name
([
])
Relationship to Child
Home Phone
Relationship to Child
Home Phone
(
(
(
([
)
Cell Phone
)
Work Phone
)
Cell Phone
Address
Address
City, ST ZIP Code
City, ST ZIP Code
])
Work Phone
Alternative Emergency Contacts
Primary Emergency Contact
Secondary Emergency Contact
(
)
(
)
Relationship to Child
Home Phone
Relationship to Child
Home Phone
([
(
(
([
])
Cell Phone
)
Work Phone
)
Cell Phone
])
Work Phone
Medical Information
Date - Documentation of Current Immunizations Received
Allergies (especially any food allergies)
Special Diet
Epi-Pen?
Date - Pen and Physician’s Orders Received
Other Special Health Considerations (which may affect performance or require treatment / precautions during school)
School History
Has your child previously attended daycare or preschool?
If so, please list the name of the facility and dates he/she attended:
Daycare / Preschool
Dates of attendance
Daycare / Preschool
Dates of attendance
_____/_____/_____
Parent / Guardian Signature
Date
ADDITIONAL REQUIREMENTS
FOR ROLE MODEL POSITION IN REVERSE-INCLUSION PILOT PROJECT
Please answer the following questions.
1. Why are you interested in having your child attend this inclusion program?
2. Why do you think your child would make a good role model for this program?
3. Please give an example of how your child communicates with other children
in social settings (e.g., birthday parties, playgroups, etc.).
When your 4-page packet is received, you will be contacted to schedule a Screening
appointment for your child. When your child comes for the screening, copies of the following
information will be required:
The parent/guardian’s picture ID
A state or military birth certificate
*Proof of residence (a lease, deed, or current utility bill showing parent/guardian
name and address; cable and phone bills are not accepted; a notarized residency
verification will be required if you are residing in someone else’s home).
* PPS employees are not required to show proof of residence.
Proof of immunizations (up-to-date shot record)
Current physical from child’s doctor
Custody documents, if applicable
Only students with completed packets will be considered for the program. Packets are
considered complete when the screening and observation have been done and all documents
have been submitted. We recommend that you provide all application materials prior to the
screening process since we will only consider completed application packets.
If you have additional questions about the Reverse Inclusion Program, please contact the
Office of Special Education at (757) 393-8471. Completed packets must be returned by April
17, 2015 to the Office of Special Education Attention Lisa Gehring or Angela McGee at 2801
Turnpike Road, Portsmouth, VA 23707.
DEVELOPMENTAL QUESTIONAIRE
Please complete the following check-list regarding your child’s development and turn it in with your
completed application to the Office of Special Education by April 17, 2015.
Child’s name
Parent/Guardian Name
_____________________________________________________
Phone Number
___________
SELF-HELP SKILLS
YES
SOMEWHAT NOT YET
Child uses the bathroom independently with the exception of fasteners
and wiping.
Child washes and dries hands with minimal assistance.
Child independently removes/puts on coat and shoes.
Child puts away toys in an appropriate place when asked.
Child feeds self independently.
Child drinks from a cup.
SOCIAL SKILLS
Child easily separates from parent or caregiver.
Child shares toys with other children.
Child takes turns with minimal assistance.
Child plays cooperatively with peers without adult assistance.
Child follows directions with minimal adult intervention.
Child follows rules given by adults for new activities or simple games.
Child can attend to an activity for 10 minutes.
GROSS MOTOR SKILLS
Child can move within environment safely and independently.
Child can climb up and down stairs independently.
Child can navigate playground equipment independently.
FINE MOTOR SKILLS
Child can hold a crayon and make purposeful marks on appropriate
surfaces.
Child demonstrates age appropriate coordination (puzzles and
pegboards).
LANGUAGE SKILLS
Child greets adults and peers appropriately.
Child converses with adults and peers.
Child’s speech is easily understood by an unfamiliar listener.
Child speaks in phrases or sentences.
Child recites parts of songs, Nursery rhymes or finger-plays.
Child answers “wh” questions appropriately (what, where, who).
COGNITIVE SKILLS
Child names colors (red, yellow, blue, green and purple).
Child names shapes (circle, square, and triangle).
Child names pictures.
Child counts to 5.
reverse-inclusion Program
PARENT AGREEMENT
PLEASE READ EACH OF THE FOLLOWING STATEMENTS
AND SIGN BELOW TO INDICATE YOUR AGREEMENT WITH OUR POLICIES:
o To be considered for position as a role model student in the Reverse-Inclusion Program, I
understand that my child must:
be 3 years old by June 30, 2015 but 4 years old after October 1, 2015.
be able to independently take care of his/her toileting needs.
have successfully completed a developmental screening and observation.
not be receiving special education services.
have provided all enrollment documents listed on the Additional Requirements page.
o Should my child be selected to participate in this program, I understand:
acceptance is for the 2015-2016 school year only. Parents will be responsible for registering
their children in the 4 year old program the following year.
Transportation will only be provided to students who are picked up or dropped off in the same
zone as their preschool center.
my child should arrive at school and be picked up on time every day and have good
attendance.
my child’s acceptance into this program is based on the belief that he/she is developmentally
appropriate for his/her age, and ready to participate as a positive role model for others. Should
my child have difficulty adjusting to the classroom environment or interacting with children
with special needs, he/she may be asked to withdraw from the program.
By signing below I indicate that I have read all statements above and agree to the policies of the
Reverse Inclusion Program.
Parent/Guardian Signature
Date___/___/___
OFFICE OF SPECIAL EDUCATION
Lisa Gehring, Program Specialist
2801 Turnpike Road, Portsmouth, Virginia 23707
Phone: (757) 393-8471 Fax: (757) 393-5289