Applicant Name District Date Submitted Interview Date Project SEARCH High School Transition Program Intern 2017 2018 Project SEARCH Timeline Thursday, February 2, 2017 Open House (St. Luke s Bethlehem) Joint with VIP Program Tuesday, February 28, 2017 Target Date to Submit Application (Interview guaranteed if submitted on time. Applications will still be accepted after this date.) March 22, 23, & 24, 2017 Intern Interviews and Selection for 2017 2018 School Year June 2017 IEP Meetings for the 2017 2018 School Year Questions or Concerns? Call Melissa Johnson at (610) 769 4111 ext. 1058 or email johnsonmelissa@cliu.org
Page 2 Application Purpose The purpose of this application packet is to outline the skill set of the Project SEARCH intern 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 SEARCH High School Transition Program and reach the outcome of integrated competitive employment. Application Guidelines: 1. All students are to complete this packet of information to be considered for participation in the Project SEARCH High School Transition Program. See checklist below. 2. Return completed packet by Tuesday, February 28, 2017 to: Melissa Johnson, Project SEARCH Supervisor Carbon Lehigh Intermediate Unit #21 4210 Independence Drive Schnecksville, PA 18078 Fax to: 610 769 1098 or Scan to: johnsonmelissa@cliu.org If you have any questions or concerns, please contact Melissa Johnson at 610 769 4111, ext. 1058 or johnsonmelissa@cliu.org 3. The *Selection Committee will review the applications, schedule interviews and if accepted, match the student skill set and interests with the Project SEARCH High School Transition Program. 4. Seventeen students will be accepted into Project SEARCH each year. A phone call and an acceptance letter will be sent to the newly selected interns. A letter will be sent home informing all other applicants of the decision. 5. Upon selection, the interns and parent(s)/guardian(s) will be asked to attend an Introductory Meeting in June and an Informational Meeting in August. The goals of these meetings are to answer questions and ensure all additional paperwork is completed before Project SEARCH begins in September. 6. Individualized Education Plan (IEP) will be developed with the IEP team for the 2017 2018 school year by June 2017. * The Project SEARCH Selection Committee may include the CLIU Special Education staff and administrators, Office of Vocational Rehabilitation (OVR), and Goodwill Keystone Area. Application Checklist Completed Application. Two letters of recommendation. **teacher, employer, WBL job coach, guidance counselor, etc. Photo. Current Individual Education Plan (IEP) Current Reevaluation Report. *Include Most Recent Math and Reading Scores/Grade Levels and IQ Scores. High School Transcript with Attendance. Sign attached Release forms at the end of the application packet for your school district, Office of Vocational Rehabilitation (OVR), and Goodwill Keystone Area.
Page 3 The following information is to be completed by applicant, parents/guardians, and/or teachers collaboratively: PERSONAL DATA Applicant Name Last First Middle Address Street District of Residence: City Zip Code School Currently Attending: Date of Birth: Male Home Phone Female Cell Phone E mail address SSN Applicant Lives With Relationship Cell Phone E mail address Parent/Guardian Information Parent/Guardian Name: Parent/Guardian e mail: Address: Street City Parent/Guardian Home Phone: Zip Code Cell Phone: Parent/Guardian Place of Employment: Parent/Guardian Work Number: Email Address: Preferred Contact Time and Method: What is your primary language? English Sign Language Spanish Other
Page 4 EMPLOYMENT BACKGROUND The goal is for every intern to become competitively employed during or upon graduation of Project SEARCH. PART TIME EITHER Do you want to work: FULL TIME Which shift would you prefer working after graduating from Project SEARCH High School Transition Program? 2nd Shift 3rd Shift 1st Shift Are you willing to work: Weekends Evenings Both Do you plan to work during the school year, in addition to being in the Project SEARCH High School Transition Program? If YES where? How many days/hours? List jobs you do or have done in school or in the community (Include Work Based Learning Experiences): Employer Job Title Job Duties 1. 2. 3. 4. 1. 2. 3. 4. 1. 2. 3. 4. 1. 2. 3. 4. Have you ever been fired from a job? If YES, please explain: Have you ever quit a job? If YES, please explain: Supervisor Name/Contact Number Paid Unpaid
Page 5 Checklist Intern: District: Age: DOB: Parent s Phone(s): IEP Expiration Date: Work Based Learning: LCTI/CCTI: If, what program? Are you aware of what your disability is? Intern s Cell Phone (This is required if you are accepted into Project SEARCH) Have you completed paperwork for Office of Vocational Rehabilitation (OVR)? (This is required to be completed before acceptance) OVR Counselor Name: Number: Email: Have you completed paperwork for Office of Intellectual Disabilities (OID)? Supports Coordinator Name: Number: Email: Applied for a waiver through Office of Intellectual Disabilities (OID)? Applied for an Autism Waiver? Any other service providers to be a part of our team? (mental health, vision, etc.) Name: Number: Email: Name: Number: Email: Completed applications for Transportation LANtaVan/LANta (This is required if you are accepted into Project SEARCH) PA State ID (This is required if you are accepted into Project SEARCH) Original SS Card (This is required if you are accepted into Project SEARCH) What was the result? Please check all possible rotations you may be interested in experiencing Bed Making Clerical Custodial Environmental Services File Clerk Food Preparation Hospitality Aide Housekeeping Landscaping Laundry Assistant Linen Assistant Mail Room Maintenance Nursing Attendant Therapy Aide Therapy and Recreation Resident Transport Warehousing
Page 6 INDEPENDENT LIVING Please list all medications taken by the student, including the dosage and time of day. Medication(s) Dosage Time of day How may your disability affect job performance (behavior, sensory, communication, academic level, etc.)? Adaptations/accommodations that you may need at work? Medical Concerns:
Page 7 STUDENT RESPONSE QUESTION Why do you want to participate in the Project SEARCH High School Transition Program? List Three References (n Related): (Student should complete in own words) (2 of the 3 references can be those who wrote letters of recommendations) Name/Relationship Phone Number Email Address 1. 2. 3. This application has been completed by: Name Title Date Signature Student Signature Date Parent Signature Date
Page 8 Parent/Guardian Input for Project SEARCH Application Project SEARCH Candidate Date Person Completing Form Competitive Employment The goal is for every intern to become competitively employed during or upon graduation of Project SEARCH. 1. Do you want to see your young adult competitively employed? 2. If so, what do you see as appropriate hours? FULL TIME PART TIME EITHER 3. As newly entering the workforce, Monday Friday 9 5 jobs can be difficult to secure, are there shifts/hours/days that are non negotiable? 4. Where do you see your young adult in 2 years and 5 years? Transportation Another goal for every Project SEARCH intern is to take public transportation (LANtaVan/LANtaBus) to the program next year. 1. Are you familiar with Independent Community Travel (ICT)? a. If yes, what do you understand ICT to be? 2. Has your young adult participated in ICT at school? 3. If your young adult becomes competitively employed during or upon graduation of Project SEARCH, how do you see him/her getting to work? LANtaBus LANtaVan Family/Friends Drive Self 4. With practice and support the first month of Project SEARCH, are you willing to have your young adult take public transportation to Project SEARCH by October? Service Agencies There are many services/supports that can assist your young adult after graduating. It is important for Project SEARCH to support the young adults and their families in understanding all the team members. 1. What do you understand Office of Vocational Rehabilitation (OVR) to be?
Page 9 Service Agencies (continued) 2. Are you familiar with the role of a Job Developer from an adult agency such as Goodwill Keystone Area? If so, what do you understand their services to be? 3. Do you have a Supports Coordinator and/or Case Manager from the Office of Intellectual Disabilities (OID)? a. If applicable, how do you think a Supports Coordinator and/or Case Manager from the Office of Intellectual Disabilities can support your young adult upon graduation? Family Advocacy It is important for our young adults to learn self advocacy skills, so they can inform others of their needs. It is helpful to hear from the family as to the supports they believe their young adult may need at work. 1. What do you consider your young adult s disability? 2. How may your young adult s disability affect job performance (behavior, sensory, communication, academic level, etc.)? 3. What adaptations/accommodations do you feel your young adult may need to be successful at work? 4. Why do you want your young adult to participate in the Project SEARCH High School Transition Program? Independence As our young adults become more independent they become more confident and sure of themselves and their decisions. This is an adjustment and journey not just for the interns, but the family as well. 1. What do you anticipate your young adults living arrangements to being 5 years and in 10 years? 2. Does your young adult have a cell phone? If yes, what do they use their cell for?
Page 10 CONSENT FOR RELEASE OF INFORMATION I hereby authorize to release/obtain (Name of School District) information from the records of (Student s Name) (Date of Birth) for the purpose of Project SEARCH High School Transition Program. The information to be released is: Comprehensive Evaluation Report Academic Evaluation Biopsychosocial History Diagnostic Summary Developmental History Discharge/Aftercare Plan Discharge Summary Other information as deemed appropriate, please list: Treatment Plans Lab Reports Medical History Medications Psychiatric Evaluation Psychological Evaluation Exchange of Verbal Information Individual Education Plan (IEP) High School Transcript with Attendance and Transition Formal and/or Informal Assessments This consent will be in effect from until. (t to exceed 1 year) I have been informed that I may revoke this authorization at any time by written, dated communication to the respective unit, except to the extent that action has been taken in reliance thereon. This form has been fully explained to me and I understand its content. Signature of parent/guardian Signature of student Signature of witness Please forward information to the attention of: (Name of facility, agency, or person) (Address) (Phone Number)
Page 11 CONSENT FOR RELEASE OF INFORMATION I hereby authorize Office of Vocational Rehabilitation (OVR) to release/obtain (Name of facility, agency, or person) information from the records of (Student s Name) (Date of Birth) for the purpose of Project SEARCH High School Transition Program. The information to be released is: Comprehensive Evaluation Report Academic Evaluation Biopsychosocial History Diagnostic Summary Developmental History Discharge/Aftercare Plan Discharge Summary Other information as deemed appropriate, please list: Treatment Plans Lab Reports Medical History Medications Psychiatric Evaluation Psychological Evaluation Exchange of Verbal Information Individual Education Plan (IEP) To provide your contact information and to discuss vocational planning. This consent will be in effect from until. (t to exceed 1 year) I have been informed that I may revoke this authorization at any time by written, dated communication to the respective unit, except to the extent that action has been taken in reliance thereon. This form has been fully explained to me and I understand its content. Signature of parent/guardian Signature of student Signature of witness Please forward information to the attention of: (Name of facility, agency, or person) (Address) (Phone Number)
Page 12 CONSENT FOR RELEASE OF INFORMATION I hereby authorize Goodwill Keystone Area to release/obtain (Name of facility, agency, or person) information from the records of (Student s Name) (Date of Birth) for the purpose of Project SEARCH High School Transition Program. The information to be released is: Comprehensive Evaluation Report Academic Evaluation Biopsychosocial History Diagnostic Summary Developmental History Discharge/Aftercare Plan Discharge Summary Other information as deemed appropriate, please list: Treatment Plans Lab Reports Medical History Medications Psychiatric Evaluation Psychological Evaluation Exchange of Verbal Information Individual Education Plan (IEP) To provide your contact information and to discuss coordination of Services. This consent will be in effect from until. (t to exceed 1 year) I have been informed that I may revoke this authorization at any time by written, dated communication to the respective unit, except to the extent that action has been taken in reliance thereon. This form has been fully explained to me and I understand its content. Signature of parent/guardian Signature of student Signature of witness Please forward information to the attention of: (Name of facility, agency, or person) (Address) (Phone Number).