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Summer Experience 2020 (Fairleigh Dickinson University)

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This program is offered by FDU’s Regional Center for Learning Disabilities.
Early applications are encouraged as enrollment is limited to ensure maximum personal attention.
The deadline for application is June 25, 2020.
I. Personal Information
B Mr. B Ms.
Student Name ________________________________________________________________________________________________________
Last First Middle
Date of Birth___________________________________ Student Cell Phone ____________________________________________________
Student Email ________________________________________________________________________________________________________
Permanent Address ___________________________________________________________________________________________________
Street City State Zip
Name of Parent/Guardian ______________________________________________________________________________________________
Home Phone ___________________________________ Parent/Guardian Cell Phone __________ __________________________________
II. School Information
Current School ________________________________________________________________________________________________________
Name
Anticipated Date of Graduation B June 2020 B June 2021 B Other ___________________________________________________
Guidance Counselor Name _____________________________________________________________________________________________
Phone _______________________________________________________________________________________________________________
Fairleigh Dickinson University’s Summer Experience offers three options.
Please indicate your desired program of study:
B College Skills Preparation (9 a.m.–1 p.m.) • Cost: $950
B College Skills Preparation & Math Workshop (9 a.m.–3 p.m.) • Cost: $1,450
B College Skills Preparation & Reading Workshop (9 a.m.–3 p.m.) • Cost: $1,450
REGIONAL CENTER FOR LEARNING DISABILITIES
Summer Experience 2020
For Students with Language-Based Learning Disabilities
Application for Admission
July 6-16 (Monday thru Thursday)
Please Print
III. Related Academic Information
TO THE STUDENT: Please answer the following in your own handwriting.
1. What, if any, special education supports did you receive in high school (e.g., resource center, collaborative support,
replacement classes, supplemental support and/or special private school). How did they help you?
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
2. How do you feel you will benefit by attending the Regional Center Summer Experience?
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
3. Please rate your skills in the following area (from 1 to 5, with 1 being weakest and 5 being strongest)
__________ Time Management __________ Study Skills __________ Computer Literacy
__________ Research Skills __________ Self-advocacy __________ Social Skills
IV. Additional Admission Requirements
In addition to this application, the following must be forwarded to the address below for this application to be complete:
1) Two letters of recommendation (one from a teacher and one from the guidance counselor) attesting to your motivation,
behavior and attitude.
2) Documentation of a learning disability (current IEP if a classified student or current evaluation report by a qualified professional
conducted within the last three years if not classified).
3) A clear photocopy of your medical insurance ID card and the following information:
Name of Your Medical Insurance Provider________________________________________ Policy/Group Number ___________________
NOTE: This information is required per University policy.
4) A $100 nonrefundable application fee, made payable to Fairleigh Dickinson University. (This fee will be credited against the total cost
of the program if admitted.)
V. Applicant Signature
I/we declare that the information reported above is true, correct and complete to the best of my/our knowledge.
_____________________________________________________________________________________________________________________
Signature of Applicant Date
_____________________________________________________________________________________________________________________
Signature of Parent or Guardian (Required if applicant is under 18) Date
Complete and mail to:
Summer Experience 2020
Fairleigh Dickinson University
Regional Center for Learning Disabilities
285 Madison Ave. • M-MS0-07, Madison, NJ 07940
Phone: 201-692-2716
fdu.edu/ld
Complete and email to:
bbyrnes@fdu.edu
2020 Summer Experience
Fairleigh Dickinson University
Regional Center for Learning Disabilities
fdu.edu/ld
:
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Completed 21 August 2020

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