Student Application Purpose & Guidelines

(Modified from the Bridge to Independent Living program at Roberts Wesleyan College)

The purpose of this application packet is to outline the skill set of the Rochester City School District or Lifetime Assistance, Inc. student candidate applying to the TPSIDProgram at Monroe Community College, which is based on the Damon City Campus. 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 successfully achieve a certificate in theTPSID program at MCC’s Damon City Campus and reach the outcomes of academic enrichment, socialization and the acquisition of skills necessary for sustainable gainful employment.

The Selection Process includes the following guidelines:

  1. To ensure proper assessment, all students must complete this packet of information to be considered for participation in the TPSIDProgram at MCC’s Damon City Campus.
  1. All students will attend an informational meeting and visit the host college site to experience a sample schedule, meet various instructors, and review potential unpaid internship sites prior to being selected to participate in TPSD at MCC’s Damon City Campus.
  1. The Selection Committee will match the student’s skill set, academic interests, social activities and internship experiences to maximize job skill building and the opportunity for sustainable gainful employment.

Application

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

Candidate Name: / Today’s Date:
Candidate Address: / DOB:
HomeSchool District:
Father/ Guardian
Place of employment / Home Phone:
Email Address: / Work Phone:
Mother/ Guardian
Place of employment: / Home Phone:
Email Address: / Work Phone:
ACCESS-VR Counselor Name:
Email Address: / Work Phone:
DDSO Status: / Eligible ____Yes ____No / If yes: / Service Coordinator:
Agency:
Medicaid Status / Eligible_____Yes _____No / Contact:
  1. Academic Interests

Please identify any academic areas of interest.

Interest Areas / Some Interest / No Interest
Human Services
Education/Childcare
Criminal Justice
Physical Education
Communication:
  1. American Sign Language
  2. Speech and Theater

Sociology
Sciences
Other:
  1. Social Activities Interests

What social activities or hobbies do you enjoy participating in? What sorts of activities or clubs might you be interested in at MCC’s Damon City Campus?

______

______

______

______

______

______

  1. VOCATIONAL/EDUCATIONAL TRAINING:

Have you taken any career/technical education courses?

Yes / No

If yes, which course was taken, and did you complete the course?

EMPLOYABILITY SKILLS:

Select the level that applies:

Category / Behavior Assessment / Never / Sometimes / Frequently
Leadership / Collaborate to accomplish goals
Personal / Is motivated
Personal / Is easily distracted
Personal / Tires easily
Personal / Is easily frustrated
Personal / Is attentive in class
Personal / Accepts supervision
Team Work / Knows teamwork required at work
Team Work / Sensitive to cultural, gender and generational differences
Team Work / Uses good manners and respects others property
Team Work / Ask for assistance, clarification, or direction when necessary
Team Work / Manages conflict and stress
Ethics / Honest
Work Ethic / Willing to take assignments or tasks
Work Ethic / Works at acceptable speed for tasks
Work Ethic / Begins a new task without prompting
Work Ethic / Takes pride in his/her work
Work Ethic / Demonstrates a positive attitude
Job Standard / Follows dress code; clean clothing
Job Standard / Shows good hygiene and grooming
Job Standard / Arrives and leaves on time, including meals and breaks
Job Standard / Attends class and work on a daily basis with 95% attendance
Job Standard / Recognizes and copes with frustration in the workplace
Job Standard / Keeps work area clean and orderly
Communication / Receives constructive feedback well from supervisors and instructors
Communication / Shows effective listening skills
Communication / Maintains appropriate conversation with others in the workplace

EMPLOYMENT BACKGROUND:

List jobs you do or have done in school or in the community either voluntary or paid:

Employer / Job Tile / Job Duties / Supervisor Name / Contact Number / Paid / Unpaid/
Voluntary

Have you ever left employment for any reason?

Yes / No

If yes, please explain:______

______

  1. TRANSPORTATION:

How do you plan to get to MCC’s Damon City Campus?

I currently drive?

Yes / No

I have plans to get my driver’s license in the next year?

Yes / No

I have experience riding public transportation?

Yes / No

If not, I am willing to complete Travel Training?

Yes / No

I live on or near a public bus route?

Yes / No

I will need assistance to plan my transportation to/from MCC’s Damon City Campus.

Yes / No
  1. SERVICE AGENCIES:

What agency services have you utilized in the past (other than ACCESS-VR and DDSO)?

Agency Name: / Purpose:
  1. INDEPENDENT LIVING:

Medications/ dosage/ Time of day taken by student

Medication / Dosage / Time of day / Self-Administered

List any health or medical issues that may impact a successful job placement:

Do you get up in the morning on your own?

Yes / No
Do you wear glasses? / Do you wear contacts?
I have no vision problems
Explain:

If you are hearing impaired, please list what kinds of aids/supports you use?

Do you use sign language?

Yes / No

Do your parents/guardians/family members sign?

Yes / No

If you have a physical disability, please list what kinds of aids/supports or assistive technology that you use?

Please list any limitations that impact employment:

  1. BEHAVIORAL SUMMARY:

Do you have any behaviors that might impact a successful college placement?

Yes / No

Please Explain:

Are you able to get along with peers and adults in school, socially or a work site?

Yes / No

Please Explain:

Have you ever been convicted of a crime?

Yes / No

Please Explain:

  1. STUDENT RESPONSE QUESTIONS

Student must respond with at least 4-5 sentences in answering these questions.

What do you know about the TPSID program at MCC’s Damon City Campus?(Complete in your own words)

Why do you think the TPSID programwould be beneficial to you? What do you hope to gain? (Complete in your own words)

This application has been completed by:

______

Name, relationship to student (self, parent, teacher)Date

______

Student SignatureDate

Student Contract

Upon program acceptance, the student and parent/guardian will read, sign, and date the contract below.

I, ______, understand that I have been accepted into the TPSID program at MCC’s Damon City Campus and must abide by the following terms and conditions:

  • I will complete the academic, social and internship requirements.
  • I will regularly attend the program per RCSD schedule.
  • I will dress appropriately and wear required attire.
  • I will call or email my instructor, internship supervisor and/or my support team when I am absent or tardy.
  • I will make up any instructional work missed due to excused absences as appropriate.
  • I understand that I am responsible for transportation to the college.
  • I will follow all the rules established by the program and college.
  • I will attend scheduled meetings with my support team, parents, teachers, and mentors.
  • I will be an active participant and communicate any issues to my support team.
  • I will participate in college social events and activities per my schedule.

I have read the above terms and conditions and agree to accept my placement in the TPSID program at MCC’s Damon City Campus. I understand that I may be asked to leave the program if Ifail to follow the terms and conditions.

______

Student Signature Date

______

Parent/Guardian Signature Date

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