2017 Application (Part 2A)

2017 Application (Part 2a)

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

Please complete with ink or type. An electronic version of this application is available through the Project SEARCH office. Please email if you would prefer the electronic application. The electronic application must be printed and signed prior to submission.

A. / Personal Data
Student / Student
Name:
Last / First / Middle
Address:
Street / City / Zip Code
School Currently Attending:
Home Phone: / Student Cell Phone: / e-mail:
Date of Birth: / Choose One:
(optional) / Male Female
Parent/Guardian / Name: / e-mail:
Address:
Street / City / Zip Code
Home Phone: / Cell Phone: / Work
Phone:

Is the above person a legal guardian to the above named student as granted by the courts? Yes No If yes, please attach guardianship paperwork.

B. / Your signature below shows agreement to the following terms:

1. Trial Period: A two-week trial period at the start of the program year will be required of all accepted enrollees.
2. The goal of Project SEARCH is paid community employment at the conclusion of the one school year program (September 2017-June 2018).

Student Signature / Date:
Parent/Guardian
Signature / Date:
C. / Future Employment & Background:

1. How do you want to be employed in the community upon completion of Project SEARCH?

Full time / Part time / Where?______

1. Would you be willing to work holidays and/or weekends?

Yes / No / If no, why not?______

1. Do you plan to work during the school year, in addition to being in the Project SEARCH program?

Yes / No
If yes where? / How many days/hours per week?

1. Do you plan to attend college during the school year, in addition to the Project SEARCH program?

Yes / No / How many classes?

5. List jobs you do or have done in school or in the community

*Include Work Experience Programs that you participated in while in high school, during summer and other volunteer jobs. Use additional paper as needed.

Employer/Organization / Job Title / Job Duties / Supervisor Name
(First & Last) / Start & End Dates / Contact Phone Number(s) / Paid / Un-paid
1.
2.
1.
2.
1.
2.

Please attach additional pages to include all paid and volunteer work experience if needed.

Yes / No

May we contact the above employers?

1. Have you ever been fired from a job?

Yes / No

If yes, please explain:

1. Have you ever quit a job?

Yes / No

If yes, please explain:

1. Do you have any physical limitations that would prevent you from being able to stand or walk for up to 4 hours per day?

Yes / No

If yes, please explain:

D. / Service Agencies:

1.Do you have a Vocational Rehabilitation Counselor (IDVR)?

Yes / Name: / Phone Number:
No

2.Do you have SSI or SSDI (Social Security Benefits) or Medicaid services from the Department of Health & Welfare (H&W)? Check all that apply

SSI SSDI Medicaid

Other Benefits? Please explain: ______

3. Do you have a Targeted Service Coordinator (TSC) or Community Based Rehabilitation (CBR) worker?

Yes / Name: / Phone Number:
No / Agency: ______

4.Please list other service agencies in which you gain assistance:

Agency Name: / Phone Number:
Provider Name: / Phone Number:
E. / Student Response Question:
Why do you want to participate in Project SEARCH? Complete in your own words and/or a person assisting can write the response in the student’s own words
Please see the Project SEARCH schedule below. Are you able to fully participate in this schedule on adaily basis (Monday-Friday)?
Yes
No / If no, please explain:
Project SEARCH Schedule
During Internships / 7:15am  8:50am
9:00am1:30pm
1:00pm  2:15pm / Classroom Instruction /Job Skill Development
Work in Hospital Departments
30 minute lunch scheduled by the department
Return to Classroom
Reflection with instructor and supervisor
Further Job Skill Development
F. / References – List Three (3)
Name / Type of Reference / Phone Number / Email Address
1. / Family Reference
2. / School Reference
3. / Other Community or Agency Reference

*Attach a letter of recommendation from a non-family member to this packet.

G. / To be completed by the person assisting the student (if applicable):
Name / Title / Date
Organization / Phone Number / Email contact
Signature of person assisting the student

Nondiscrimination Notice

The Coeur d’Alene School District complies with all applicable laws and does not discriminate on the basis of race, color, religion, sex, national origin, age (40 or older), genetic information, veteran status or disability in any educational programs or activities receiving federal financial assistance or in employment practices. The District provides equal access to the Boy Scouts and other designated youth groups.

Inquiries regarding compliance with this nondiscrimination policy may be directed to the Section 504 Program Coordinator or Director of Human Resources at the District Administrative Center, 1400 N. Northwood Center Ct., Coeur d’Alene, Idaho 83814-2472, (208) 664-8241.

2017Consent for School Records

I, ______(adult student or court appointed guardian), hereby by give consent for the Project SEARCH selection committee (including members from the Coeur d’Alene School District, Post Falls School District, Vocational Rehabilitation, Kootenai Health, Tesh and a community member) to gather and review school documents (including the Project SEARCH application, IEP, transcripts/grades, and attendance records) for the sole purpose of consideration for the Project SEARCH at Kootenai Health program.

Student Signature / Date:
If applicable, Court Appointed Guardian
Signature / Date: