STUDENT INFORMATION Guardianship: Self Parentother

Austin I.S.D. GO Project

Application Of Services

Date

STUDENT INFORMATION Guardianship: Self ParentOther

Student Name:

Address: Phone:

Parent Name: Work/Cell Phone:

Current School Attending:

Student’s Case Manager: Phone #:

D.O.B.: Student I.D.#:

Expected Date Of Graduation (Exiting Services from AISD):

Date Student Reaches Age 22:

Agencies student receives services from (DARS, CLASS, DADS, etc):

Student’s Volunteer Work Experience (CBVI):

Student’s Paid Work Experience:

Additional Comments:

Please Attach or Mail Copies Of The Following Documents:

REQUIRED DOCUMENTS:

q  Guardian / Adult Student Agreement

q  Official AAR (Transcript)

q  Counselor Credit Check

Submit application to: Tammy Smith GO Project Coordinator

Austin ISD-Rosedale 414-0960,

GO STAFF USE ONLY: Date Received:

Waiting List

GO Site: ______APPLICATION:

ACCEPTED DENIED

Status:

q  Student Observation:

q  Family Interview

q  Family Site Visit:

Guardian / *Adult Student Agreement

* Adult Student Maintaining Guardianship

GO Project Austin ISD

Name Of Student:

Name Of Parent:

Guardianship: Parent Student Other

Parent Address:

Parent Phone: (HM) (CELL)

Please mark your responses

·  I understand that my site preference will be noted, but placement at a particular GO site is NOT guaranteed. YES NO

*** All GO sites emphasize programming as it relates to transition.

·  I understand that if accepted, the student is on a probationary status for 6 weeks. If placement is deemed inappropriate, student will return to home campus or alternate programming or graduation will be considered. YES NO

·  I understand that the GO Project is a transition program and instruction encompasses the following areas: employment, independent living, life long learning, recreation and leisure, functional academics and community access. YESNO

·  My student qualifies for Free/Reduced Lunch. YESNO

Please fill in the blanks

List any medical conditions we should be aware of regarding your son/daughter:

List any medication your son/daughter takes and the time of day it is taken:

List any support/assistance your son/daughter needs in the area of self help (hygiene, toileting, eating, etc):

Date:

Signature of Parent/Guardian or Adult Student In Agreement