Center for the Retarded, Inc

GENERAL INFORMATION

Project CASE is a program designed to provide support for students with developmental disabilities in their pursuit of academic achievement that will lead to a student’s personal employment and career goals. Students are expected to meet the same expectations and criteria of any other qualified student attending Texas Tech University or South Plains College. This means you as a student must complete all required coursework and meet the technical requirements of your selected program. Coursework, curriculum, and/or educational programs cannot be altered or modified in any way.

Due to the nature of the work involved in a selected career, certain conditions may prohibit an individual from safely and accurately performing the tasks required to be employed. Such conditions may preclude admission to specific programs. If you are unsure whether or not you can meet the program requirements due to your disability, please contact the specific program you are interested in at Texas Tech University or South Plains College. You may also contact your campus Student Disability Services Office.

By signing below, I acknowledge that I am able and willing to work to meet all technical and academic requirements of the program of study that I have selected. I agree to actively pursue a certification or degree within 4 years of acceptance to Project CASE. I also agree to participate in all Project CASE meetings and business internships as long as they do not interfere with my scheduled classes. I also acknowledge that I agree to allow information about my academic and vocational outcomes while in the program to be used as part of a research study documenting the effects of Project CASE.

I understand that admission and/or enrollment into either Texas Tech University or South Plains College does not automatically grant admission into Project CASE or the program of study I have chosen. I understand that the Project CASE program and research study will only accept a limited number of students each year on each campus. In order to complete my application for Project CASE, I understand that my application will be reviewed and I will be contacted to set up a personal interview with the Project CASE staff at TTU or SPC.

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SignatureDate

Date of Application: ______

NAME OF APPLICANT: ______

Last NameFirst NameMiddle Initial

COLLEGE ELIGIBILITY ______Yes, please provide proof of acceptance to:

_____Texas Tech University ______South Plains College

Are you registered with the Office of Disability Services? __YES ____NO

Name of your contact at your campus Office of Disability Services ______

What is your documented disability? ______

PRESENT ADDRESS:Street Address: ______

City: ______State: ______Zip: ______

PHONE NUMBER: [Home] (____) ______[Cell phone] (____) ______

EMAIL:______

DATE OF BIRTH: ______GENDER:  Male  Female

NAME OF EMERGENCY CONTACT: ______

Relationship to Applicant: ______

Address: ______

City: ______State: ______Zip: ______

Phone: [Home] (____) ______Other/Emergency (____) ______

PRIMARY LANGUAGE:  English  Spanish  Other, specify: ______

What are your goals and interests in finding a job after college?

______

______

______

Are you currently receiving services through the Department of Assistive & Rehabilitative Services (DARS)? ___YES _____NO

Name of your DARS contact ______

Phone number for DARS contact ______

If you are not currently receiving services through the Department of Assistive and Rehabilitative Services (DARS), are you willing to apply within the first semester with Project CASE if you need job coaching or other Vocational Rehabilitation services from DARS?

_____YES ____NO

______(initial here that you understand the following statement) One of the major goals of Project CASE is to assist students in their career pursuits through their successful completion of a technical certification or academic degree that will prepare them for work in their chosen field; however, Project CASE cannot guarantee any student a specific job once they complete their program of study.

Are you a United States citizen? _____YES _____NO ETHNICITY: ______

LEGAL STATUS

Name of Parents or Guardian: ______

Relationship to Applicant: ______

Address: ______

City: ______State: ______Zip: ______

Phone: [Home] (____) ______[Other/Emergency] (____) ______

Do you have dependants under the age of 18 currently living with you? If so, how many?

If so, do you have reliable child care in order to attend classes? ____YES _____NO

Do you need assistance with child care to insure your regular attendance in class? ____YES ____NO

Do you currently take medications?  Yes  No

If so, what are the names of your medication(s)? ______

EXISTING MEDICAL CONDITIONS/DIAGNOSES: (i.e., seizures, severe allergies) ______

______

ADAPTIVE EQUIPMENT  No  Yes, please explain: ______

______

EDUCATION/SERVICES/EMPLOYMENT

EDUCATION (schools attended)

CURRENT SERVICES (includes vocational, job training, in-home care, etc.)

Case Manager or other Agency Contacts:

PREVIOUS SERVICES (includes vocational, job training, in-home care)

CURRENT EMPLOYMENT

PREVIOUS EMPLOYMENT

REFERENCES

Please provide a Recommendation Form to at least 2 individuals who know you well, but are not related to you. Have them mail the completed forms to Project CASE as noted on the Recommendation Form. Your application is not complete until these references are received.

TRANSPORTATION

In order to participate in Project CASE, students must be able to have reliable transportation to and from the campus to attend classes and meet with the Project CASE staff. Additional transportation may be required to and from internship sites or employment.

TRANSPORTATION (check all that apply)

 Family/Friends Provide Transportation Agency (group home) Provides Transportation

 Uses City Bus/Cab Independently Operates Own Vehicle (Car/Bike)

 Other, ______

Name of Contact for Transportation (if other than yourself):

______

LEGAL ISSUES

Has the Applicant ever been Convicted (or adjudicated) of a public offense?  No  Yes

If yes, please explain:

Your application will not be considered complete until your completed application has been submitted to Project CASE in the College of Education, Burkhart Center, Box 41071,

2902 18th Street, Lubbock, Texas 79409. Once you have a completed application, your application will be reviewed and your will be contacted by the Project CASE staff. If you have further questions, please contact the Project CASE Director, DeAnn Lechtenberger

I agree that the information provided is, to the best of my ability, accurate and complete.

______

Applicant Signature Date

______

Guardian Signature (if appropriate) Date

Project CASE: Connections for Academic Success and Employment

Recommendation Form #1

For a complete application to be processed, two recommendation forms must be received by the Project CASE staff.

To the applicant: Complete the information requested below and give this form to the person serving as a reference along with a stamped envelope addressed to Dr. DeAnn Lechtenberger, Texas Tech University, Burkhart Center-College of Education, Box 41071, 2902 18th St., Lubbock, TX 79409.

Applicant’s Name:

______

Last First Middle

I, the applicant, waive my rights to ever see this form and any supplementary notes or letters attached to this recommendation.

______

Student Applicant’s Signature Date

Applicant: Do Not Write Below Line

______

To the recommender: The person named above is applying for admission to Project CASE at Texas Tech University or South Plains College. Project CASE is a specialized program designed to provide support for students with disabilities in their pursuit of a postsecondary degree or certification that will lead to a student’s personal career goals. Thank you for your assistance.

1. How long have you known the applicant? ______

2. How well do you know the applicant?

(Circle response that is most applicable): casually fairly well very well

3. In what capacity have you known the applicant? ______

______

______

4. Please rate the applicant on the characteristics shown below in comparison to students at the undergraduate level, and use the scale below where

1 = weak, 2 = fair, 3 = good, 4 = strong, and NA = not applicable or can’t judge.

Dependability1234

Interpersonal skills1234

Flexibility to handle change1234

Ability to focus and meet deadlines1234

Persistence to complete college degree/certificate1234

Academic ability to be successful in college1234

Problem solving skills1234

Enjoys learning new things1234

Expresses wanting to attend college 1234

Expresses the desire to be employed1234

Independence1234

5. Please write a few sentences on your estimate of the applicant’s chances of successfully completing a postsecondary certificate or program of study.

6. Please share your opinion of the applicant’s likely performance in an employee, volunteer, or internship position once the applicant has completed a postsecondary program of study or certificate program. Statements about the applicant’s emotional maturity and stability, character and integrity, and interpersonal skills will be helpful.

Recommender’s Name: ______Date: ______

Position: ______

Address: ______

Phone: ______Email______

Thank you for your assistance. Please return this form to:

DeAnn Lechtenberger

Texas Tech University

Burkhart Center, College of Education

Box 41071

2902 18th Street

Lubbock, TX 79409

Project CASE: Connections for Academic Success and Employment

Recommendation Form #2

For a complete application to be processed, two recommendation forms must be received by the Project CASE staff.

To the applicant: Complete the information requested below and give this form to the person serving as a reference along with a stamped envelope addressed to Dr. DeAnn Lechtenberger, Texas Tech University, Burkhart Center-College of Education, Box 41071, 2902 18th St., Lubbock, TX 79409.

Applicant’s Name:

______

Last First Middle

I, the applicant, waive my rights to ever see this form and any supplementary notes or letters attached to this recommendation.

______

Student Applicant’s Signature Date

Applicant: Do Not Write Below Line

______

To the recommender: The person named above is applying for admission to Project CASE at Texas Tech University or South Plains College. Project CASE is a specialized program designed to provide support for students with disabilities in their pursuit of a postsecondary degree or certification that will lead to a student’s personal career goals. Thank you for your assistance.

1. How long have you known the applicant? ______

2. How well do you know the applicant?

(Circle response that is most applicable): casually fairly well very well

3. In what capacity have you known the applicant? ______

______

______

4. Please rate the applicant on the characteristics shown below in comparison to students at the undergraduate level, and use the scale below where

1 = weak, 2 = fair, 3 = good, 4 = strong, and NA = not applicable or can’t judge.

Dependability1234

Interpersonal skills1234

Flexibility to handle change1234

Ability to focus and meet deadlines1234

Persistence to complete college degree/certificate1234

Academic ability to be successful in college1234

Problem solving skills1234

Enjoys learning new things1234

Expresses wanting to attend college 1234

Expresses the desire to be employed1234

Independence1234

5. Please write a few sentences on your estimate of the applicant’s chances of successfully completing a postsecondary certificate or program of study.

6. Please share your opinion of the applicant’s likely performance in an employee, volunteer, or internship position once the applicant has completed a postsecondary program of study or certificate program. Statements about the applicant’s emotional maturity and stability, character and integrity, and interpersonal skills will be helpful.

Recommender’s Name: ______Date: ______

Position: ______

Address: ______

Phone: ______Email______

Thank you for your assistance. Please return this form to:

DeAnn Lechtenberger

Texas Tech University

Burkhart Center, College of Education

Box 41071

2902 18th Street

Lubbock, TX 79409

Revised 12-10-131