200 Hour DS PATHS Certificate Program Application for Admission and Enrollment Agreement

Transcription

1 200 Hour DS PATHS Certificate Program Application for Admission and Enrollment Agreement Personal Information Legal Name: Last/Family First Middle/Maiden Social Security Number: - - Permanent Mailing Address: (include street & number, city, state, and zip) Correspondence will be mailed to this address. Home Phone: Work Phone: Cell Phone: Address: Date of birth: / / Month Day Year Gender: Male Female Nation of Citizenship: United States Other: Immigration Status: Permanent Resident Alien (copy required) Refugee (copy required) Visa Type (copy required) Voluntary response is requested for federal regulation. This information will not be utilized in a discriminatory manner. (please check one only) American Indian or Native Alaskan Asian or Pacific Islander Black (non-hispanic) Hispanic White (non-hispanic) Indicate Session You are Applying For (including anticipated ending dates): Session I CIP (January 27, 2016 June 15, 2016) Session II CAP (August 17, 2016 December 21, 2016) Session III (TBD, if needed) WPSession I (TBD, if needed) Occupational or Professional Experience: Indicate past work experience. Position/Activity Location include city and state From Mo/Yr To Mo/Yr / / / / / / Emergency Contact Name: Relationship to Student: Home Phone: Cell Phone: Work Phone: Address: (include street & number, city, state, and zip) Page 1 of 11

2 Education (Please check box that applies): Graduated (High School) Graduated (College-Ready Diploma) Anticipated Date of Graduation from High School (month/year ) Completed GED Anticipated Date of completion of GED (month/year ) Received Certificate of Attendance Received Special Diploma High School Attended or Site of GED: Name of School Graduated or Completed GED (month/year) City/County/State Other Intuitions Attended Name of School Graduated or Completed GED (month/year) City/County/State Name of School Graduated or Completed GED (month/year) City/County/State Other Degrees/Certifications Possessed Have you ever been incarcerated, convicted of a felony, or experienced disciplinary problems at another educational institution? YES NO If yes, please submit a written statement explaining the circumstances to the Director of Learning for review before admission to. This information will be handled confidentially. Page 2 of 11

3 Admission Requirements 1. Must be at least 18 years of age. 2. Must possess a high school diploma or GED. 3. Must be either a citizen of the United States or be a legal resident with a work permit /visa documentation. 4. Are able to meet physical requirements of the position and lift a minimum of 25 lbs. 5. Successfully complete a Level Two Background Screening, including reference checks at applicant expense. 6. Must express compassion for other human beings. 7. Has the ability to independently travel to and from training/work. 8. Is interested in learning to be an effective team member. 9. Has the ability to stand for 8 hours with normal breaks. 10. Can calculate basic mathematical computations. 11. Can read at a 9 th grade level or higher. 12. Students for the Working Professionals program must provide proof of at least 40 hours of prior experience. For those unable to provide this documentation, the student will be required to complete an additional 40 hours of an unpaid externship. 1. Please briefly describe why you are interested in becoming a Direct Support Professional. 2. What qualities do you think that it takes to be a Direct Support Professional? Page 3 of 11

4 Terms and Conditions Applications must include the following: 1. Completed Application and Enrollment Form with all Signatures 2. Copy of any visa information (if applicable) 3. Two completed and signed original reference forms 4. Copy of High School Diploma, G.E.D or most recent transcript 5. Copy of a valid driver's license, State ID card or other proof of residence Application Deadline: Applications must be received at least one month prior to Session start dates in accordance with the DS PATHS Certificate Program Academic Calendar. Enrollment Period: The enrollment period for the program is seven (7) weeks for the Accelerated Program Sessions or ten (10) months for the Program for Working Professionals. In the event of cancellation or termination from the program, the enrollee is entitled to a refund based upon the approved Refund Policy. Classes begin promptly at 9 a.m. and run until 5 p.m., Monday through Friday for the Accelerated Program Sessions. Classes begin promptly at 9 a.m. and run until 5 p.m., every other Wednesday for the Program for Working Professionals plus a half day for the final exam. All classes take place at: ARC Broward NW 53rd Street Sunrise, Florida References Since references need to be contacted and need time to fill out the evaluation forms, it is recommended that you sign the release for each form and send those out immediately. It is helpful if you include an envelope with your name on it. The forms should be returned to you in a sealed envelope with the reference s signature across the flap. Reference check forms must be submitted in the same packet with the remainder of your application materials. Certificates and Academic Progress: Accelerated Program Participants: The DS PATHS Program Certificate will be granted to a student who successfully completes each of the thirty (32) CIP and CAP classes, final examination and the 40-hour unpaid externship. Successful completion of each class requires a score of at least an 80 percent on the quizzes/completion exercises at the end of each class and earning at least a 75 percent on the final exam at the end of the course. The student is allowed up seven (7) weeks or twenty-nine (29) academic days to complete the DS PATHS Certificate Accelerated Program. Program for Working Professionals: The DS PATHS Program Certificate will be granted to a student who successfully completes each of the thirty (32) CIP and CAP classes and final examination. Successful Page 4 of 11

5 completion of each class requires a score of at least an 80 percent on the quizzes/completion exercises at the end of each class and earning at least a 75 percent on the final exam at the end of the course. Students who participate in the DS PATHS Certificate Program for Working Professionals are allowed up to twenty-one full class days to complete all coursework over a period of ten months. Payment: All tuition must be paid prior to beginning coursework. Payment must be received no later than the Friday before the start of each session. Course Tuition: $2,000 (including all materials) plus the Level Two Background Screening Fee is $55 (payable directly to Statutory Fingerprinting by the student and is non-refundable) for total fees of $2,055 Upon successful completion of the program s 160 clock hours and externship of 40 hours of portfolio work over seven (7) weeks, the student will be awarded a Certificate for the PATHS Certificate Program. Methods of Payment Full payment at time of signing enrollment agreement. Submission of signed enrollment agreement with balance paid prior to starting date. Submission of signed enrollment agreement with balance paid prior to graduation by a payment plan. NOTE: For School offering a payment plan with four or more payments the federal boxes or vertical listing must be included on the contract. (N/A, if not applicable or line through) ANNUAL PERCENTAGE RATE FINANCE CHARGE Amount Financed The dollar amount the credit provided to you or on your behalf. Total of Payment The amount you will have paid after you have made all payments as scheduled. Total Sales Price The total cost of your purchase on credit including your down payment of % $ $ $ $ YOUR PAYMENT SCHEDULE WILL BE: Number of Payments Amount of each payment When payments are due $ Beginning on / / and on the same day each (check one) weekly or bi-weekly thereafter All prices for program are printed herein. There are no carrying charges, interest charges, or service charges connected or charged with any of these programs. Contracts are not sold to a third party at any time. Cost of class is included in the price cost for the goods and services. Financial Assistance: Students are responsible for payment of the full amount of tuition and fees charged by. Financial assistance and flexible payment plans are available to students who are eligible and qualify. Our Admissions staff can assist you in determining your eligibility and which types of financial assistance or payment plans may be available to you., at its sole discretion, may approve a monthly payment plan. With this Page 5 of 11

6 agreement on file, students will be required to make an initial payment by the registration payment deadline and will have the option of paying the balance in additional consecutive monthly payments. Current and subsequent schedule of payments shall be binding on me and made part of this agreement. Monthly payments are due on or before scheduled due dates or in full upon receipt of financial assistance, whichever comes first. Program Withdrawal Students who find it necessary to withdraw may do so by written letter directly to the Director of Learning. The date of withdrawal will be the date receives the student s request to withdraw. All money due the student will be refunded within thirty (30) days. Fees for the Level Two Background Screening are non-refundable. Cancellation and Refund: In accordance with paragraph 6E (6)(i), F.A.C., and other applicable federal and state requirements, the refund policy and procedures is as follows: CANCELLATION AND REFUND POLICY Should a student s enrollment be terminated or cancelled for any reason, all refunds will be made according to the following refund schedule: 1. Cancellation can be made in person, by electronic mail, by Certified Mail or by termination. 2. All monies will be refunded if the school does not accept the applicant or if the student cancels within three (3) business days after signing the enrollment agreement and making initial payment. 3. Cancellation after the third (3rd) Business Day, but before the first class, results in a refund of all monies paid, with the exception of the non-refundable processing fee of $55.00 required for the HRS Screenings/Fingerprinting. 4. Cancellation after attendance has begun, but prior to 40% completion of the program, will result in a Pro Rata refund computed on the number of hours completed to the total program hours. 5. Cancellation after completing 40% of the program will result in no refund. 6. Termination Date: In calculating the refund due to a student, the last date of actual attendance by the student is used in the calculation unless earlier written notice is received. 7. Refunds will be made within 30 days of termination of students enrollment or receipt of Cancellation Notice from student. Refund checks or credit card refunds will be issued ONLY to the person who made the payment. The refund will be processed within thirty (30) days after the date the refund was requested. If payment was made by credit card, will simply credit the amount back to the card within thirty (30) business days. There is no transfer of funds from one student to another. There are NO REFUNDS issued for the $55 Level Two Background Screening for any reason. Page 6 of 11

7 Deposits or refunds not claimed within six (6) months from the student's last day of school will be treated as a donation to the school. Reminder: All students are expected to complete the required Level Two Background Screening within ONE (1) WEEK of receipt of the Conditional Acceptance Letter. Career Placement Services: Career Placement Specialists at ARC Broward will assist each student with job placement skills development. However, does not guarantee job placement or employment. Since students will be working vulnerable individuals including children, adults and elderly persons with disabilities, employers are required to successfully complete a Level II Background Screening as a condition of employment, in accordance with applicable law. This security background screening requires fingerprinting for all purposes and checks including a local, statewide criminal and juvenile records check (FDLE) and federal (FBI) background screening, in addition to signing an Affidavit of Good Moral Character. Direct Support Professional Licensing: The State of Florida does not require that Direct Support Professionals complete a licensing process. However, the DS PATHS Certificate Program can serve as a starting point for professionals to complete the national voluntary credentialing available from the National Alliance of Direct Support Professionals (NADSP) that includes: Direct Support Professional - Registered (DSP-R), Direct Support Professional - Certified (DSP-C), and Direct Support Professional - Specialist (DSP- S) credentialing. For further details, refer to NADSP s Credentialing Guidebook at NADSP fees will apply for this process. Additional information regarding the institution may be obtained by contacting the Commission for Independent Education, Florida Department of Education, 325 West Gaines Street, Suite 1414, Tallahassee, Florida , toll-free telephone number (888) Completed Application Submission Options: Print and mail via regular mail, or drop off in person, the completed application form to: ATTN: DS PATHS Application Processing NW 53rd Street Sunrise, Florida If you have any questions, please contact us at: Phone: (954) , Cristina Gardner, Training Coordinator X cgardner@arcbroward.com, clima@arcbroward.com or dstein@arcbroward.com is a division of ARC Broward, a nationally accredited human services organization. Achievement Rehabilitation Centers, Inc. is a registered Florida Corporation operating under the registered fictitious name. Grounds for Termination I agree to comply with the rules and policies and understand that the School shall have the right to terminate this contract and my enrollment at any time for violation of rules and policies as outlined in the catalog. I Page 7 of 11

8 understand that the School reserves the right to modify the rules and regulation, and that I will be advised of any and all modifications. Graduation Requirements I understand that in order to graduate from the program and to receive a diploma, I must successfully complete the required number of scheduled clock hours as specified in the catalog and on the Student Enrollment Agreement, pass all written and practical examination with a 80% average, earn a 75% or above on the final exam and satisfy all financial obligations to the School. I CERTIFY that all statements given in this application are true and accurate to the best of my knowledge. I acknowledge that I have received and read a copy of the PATHS Certificate Program Student Information and Course Handbook and a copy of the Application for Admission and Enrollment Agreement. I agree to abide by Student Code of Ethics and Conduct and all other rules and regulations of ARC Broward Learning Institute. I agree that if my records are not complete within the initial term of enrollment or if any information is found to be false, I may be suspended from classes and the school s refund policy will be followed. Signature of Applicant Date Signature of Authorized Representative Date Received Page 8 of 11

9 Reference Forms Please select two personal or business references to complete the forms on pp on your behalf. Since references need to be contacted and need time to fill out the evaluation forms, it is recommended that you sign the release for each form and send these forms out immediately. It is helpful if you include an envelope with your name on it. The forms should be returned to you in a sealed envelope with the reference s signature across the flap. Reference check forms must be submitted in the same packet with the remainder of your application materials. Please see the below reference forms. Page 9 of 11

10 Applicant Name (Print) Application Deadline is January 15, 2016 Personal and Character Reference Form (One of Two) I authorize the person completing this reference request to respond fully to all questions listed on this form. Applicant Signature Date The individual named above has applied for admission to the PATHS Certificate Program at the ARC Broward Learning Institute and given your name as a personal reference. The information that you provide will enable us to process this application in expeditious manner. Kindly return this form to the applicant within 48 hours in a sealed envelope with your signature across the flap. Please answer the following questions: 1. In what capacity do you know the applicant? For how long? 2. To your knowledge, has the person ever been convicted of a crime? If yes, please explain 3. Do you think that the applicant is qualified to participate in a seven (7) week program in a facility that cares for children or any developmentally disabled persons? Why? Why Not? 4. If applicable, would you consider placing the responsibility of a child or developmentally disabled relative of yours with the applicant? Why? Why Not? 5. Additional Comments: EVALUATE Above Average Average Below Average No Knowledge Adaptability Dependability Honesty Interpersonal Skills Initiative Judgment Maturity Responsibility Self Expression Name/Signature of Reference Date Telephone Number/Address Questions: Please contact the at Page 10 of 11

11 Applicant Name (Print) Personal and Character Reference Form (Two of Two) I authorize the person completing this reference request to respond fully to all questions listed on this form. Applicant Signature Date The individual named above has applied for admission to the PATHS Certificate Program at the ARC Broward Learning Institute and given your name as a personal reference. The information that you provide will enable us to process this application in expeditious manner. Kindly return this form to the applicant within 48 hours in a sealed envelope with your signature across the flap. Please answer the following questions: 3. In what capacity do you know the applicant? For how long? 4. To your knowledge, has the person ever been convicted of a crime? If yes, please explain 3. Do you think that the applicant is qualified to participate in a seven (7) week program in a facility that cares for children or any developmentally disabled persons? Why? Why Not? 4. If applicable, would you consider placing the responsibility of a child or developmentally disabled relative of yours with the applicant? Why? Why Not? 5. Additional Comments: EVALUATE Above Average Average Below Average No Knowledge Adaptability Dependability Honesty Interpersonal Skills Initiative Judgment Maturity Responsibility Self Expression Name/Signature of Reference Date Telephone Number/Address Questions: Please contact the at Page 11 of 11