New Student Application Packet

Project SEARCHTM New Student Application Packet

2017-2018

A WNY Collaborative

This project is sponsored by the following partners:

Application Purpose & Guidelines

The purpose of this application packet is to outline the skill set of the Project SEARCHTM student candidate. This application then enables the Selection Committee* to properly assess each student candidate’s skills, abilities and background. A parent, student, counselor, teacher or employer may be contacted by the Selection Committee to gather additional information. Our final goal is to select students who will be successful in a Project SEARCHTM program and reach the outcome of competitive employment.

The Selection Process includes the following guidelines:

1. Recruitment is typically held in the spring of each year. However, there may be exceptions for entrance throughout the school year. To ensure proper assessment, all students must complete this packet of information and participate in a Work Experience Program (WEP) intake interview to be considered for participation in the Project SEARCHTM program.

2. All students are encouraged to attend an informational meeting and visit the host business site to learn about possible rotations and meet the instructor, job coaches and host business liaison prior to being selected to participate in Project SEARCHTM.

3. If selected, the Project SEARCHTM team will match the student skill set and interest with the work experiences which will maximize job skill building and the opportunity for competitive employment.

* The Project SEARCHTM a WNY Collaborative selection committee consists of representatives from the following organizations and agencies:

 Beechwood Continuing Care  Erie 1 BOCES  Aspire of WNY  The Summit Center  ACCES-VR  OPWDD

By completing and signing this application, the applicant and family hereby provide consent for these agencies to share student information during the application process, including status of eligibility with ACCES-VR and OPWDD. If accepted into Project SEARCH, these partners hereby given consent to continue to share information regarding student progress throughout participation in Project SEARCH and beyond into competitive and/or supported employment.

Please send completed application to:

John W. Pope West Elementary School 1397 Orchard Park Rd. #1 Buffalo,NY14224 (716) 821-7017 (phone) (716) 821-7218 (fax) Application

The following information is to be completed by the student, parents/guardians, and teachers collaboratively:

Candidate Name: Today’s Date:

Candidate Address: DOB:

Email Address: Cell Phone: Current School Program:

Father/Guardian Home Phone: Email Address: Work Phone:

Mother/ Home Guardian Phone: Email Address: Work Phone:

ACCES-VR Do you have an open If yes: Counselor Name: Status: ACCES-VR case?

____Yes ____No Email address:

Work phone:

OPWDD Status: Have you been approved If yes: Service for OPWDD services? Coordinator:

____Yes ____No Agency:

Medicaid Status: Do you receive Medicaid? If yes: Contact:

____Yes ____No

SSI/SSDI Status: Are you receiving SSI or If yes: Contact: SSDI benefits?

____ Yes ____No Application ~ continued

VOCATIONAL/EDUCATIONAL TRAINING:

Have you taken any career/technical education courses? Yes No

If yes, which course was taken, and did you complete the course?

Is attendance in your current career/technical education program a concern? Yes No

If yes, please describe:

Please leave BLANK (to be filled out at WEP intake interview): Summary of formative assessments (in student’s words):

EMPLOYMENT BACKGROUND:

List jobs you do or have done in school or in the community either voluntary or paid: Employer Job Tile Job Duties Supervisor Contact Paid Unpaid/ Name Number Voluntary

Have you ever left employment for any reason? Yes No

If yes, please explain: INDEPENDENT LIVING:

Do you currently have an Individual Plan of Protection? Yes No

Medications/ dosage/ Time of day taken by student Medication Dosage Time of day Self- Administered

List any health or medical issues that may impact a successful job placement:

Do you get up in the morning on your own? Yes No

Do you wear glasses? Do you wear contacts? I have no vision problems

Explain:

If you are hearing impaired, please list what kinds of aids/supports you use?

Do you use sign language? Yes No

Yes No

If you have a physical disability, please list what kinds of aids/supports or assistive technology that you use?

Please list any limitations that impact employment:

Please describe your current means of transportation: Application ~ continued

SERVICE AGENCIES:

What agency services have you utilized in the past (other than ACCES-VR and OPWDD)?

Agency Name: Purpose:

BEHAVIORAL SUMMARY:

Do you have any behaviors that might impact a successful job placement? Yes No

Please Explain:

Are you able to get along with peers and adults on a work site? Yes No

Please Explain:

Have you ever been convicted of a crime? Yes No

Please Explain:

Would you be willing to take a drug test? Yes No

Please Explain:

REFERENCES

Please include 2 letters of recommendation. Letters should provide helpful background information about your skills and abilities to the Project SEARCHTM selection committee. (Examples might include a teacher school counselor, your service coordinator, work study or job supervisor) Application ~ continued

STUDENT RESPONSE QUESTIONS (Student must respond with at least 4-5 sentences in answering these questions.)

What do you know about Project SEARCHTM? (Complete in your own words)

Why do you think Project SEARCHTM would be beneficial to you? What do you hope to gain? (Complete in your own words)

THIS APPLICATION HAS BEEN COMPLETED BY:

______Name, relationship to student (self, parent, teacher) Date

______Parent Signature Date

______Student Signature Date Student Pre-Contract

Read the student contract below and sign and date.

I, ______, understand that by signing this contract I am indicating my interest in being considered for acceptance into the Project SEARCHTM program. If I am selected, I agree to abide by the following terms and conditions:

 I will complete up to three unpaid job rotations within the host business.  I will attend the program every day, Monday through Friday, and maintain a minimum of 95% attendance to maintain my spot in Project SEARCHTM.  I will dress appropriately and wear required attire.  I will call my instructor and departmental supervisors when I am absent or tardy.  I will make up any instructional work missed due to program absences.  I will participate in a travel training assessment, and will learn to use public transportation if appropriate.  I will follow all the rules established by the program and host business.  I will attend scheduled meetings with my support team, parents, teachers, and business staff.  I will follow appropriate expectations as communicated by the departments that oversee my internships.  I will be an active participant and communicate any issues to my support team.  I will actively pursue employment.  I will work towards independence in the community.  I allow the partners of Project SEARCHTM WNY Collaborative to share information regarding my progress in the program.

I have read the above terms and conditions and agree to abide by them if I am selected to participate in the Project SEARCHTM program. I understand that I may be asked to leave Project SEARCHTM if I fail to follow the terms and conditions.

______Student Signature Date

______Parent/Guardian Signature Date