Florida Gulf Coast University

OFFICE OF ADAPTIVE SERVICES

Graduate Assistant Application

Fall 2015-Spring 2016

Name: ______Date of application: ______

Address: ______

Phone: Daytime: (_____) ______Other Phone: (_____) ______

Email: ______

Program: ______

Please describe your career goals?

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How do you envision Adaptive Services meeting your training goals and interests?

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Please briefly describe your experience with:

Working with individuals with disabilities (Psychological, Physical and/or Learning): ______

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Disability related technology (Dragon, Kurweil, Magic, Jaws, etc.): ______

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Disability related documentation (i.e. medical reports, psychological reports, etc.):

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Experience with accommodations (i.e. test proctoring, note-taking, reading, and scribing, etc.):

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Semester you entered graduate program: ______, 20__.

Semester you intend to graduate: ______, 20__ .

My faculty advisor is: ______

My field placement supervisor (from my department) is ______

Have you ever been convicted of, pled guilty to, or pled nolo contendre (no contest) to a felony or legal offense that would influence your ability to perform in this agency? (Example: sexually-based offenses, drug or alcohol offenses, domestic violence, or similar). Have you ever had any disciplinary action taken against you for being in violation of ethical/legal standards of practice by a graduate or internship training program, practicum site or employer? Have you ever been sanctioned for any policy violation at FGCU? Please explain. Answering yes to this question does not automatically disqualify you from working at Adaptive Services.

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With your application, please include:

·  A curriculum vita (a resume that includes a list of courses taken; employment and/or internship experiences; volunteer work; etc)

·  Three professional references that we may check

Bring your completed application to the Adaptive Services office in Howard Hall rm. 137 or mail to:

The Office of Adaptive Services

10501 FGCU Boulevard South

Ft Myers, FL 33965-6565

APPLICATIONS ARE DUE BY MARCH 13, 2015