SWEP 2017 (Summer Work Experience Program)

YTP/VRC REFFERAL FORM

Student Name: Student Address:

Teacher/VRC Making Referral:

Teacher/VRC Phone: Teacher/VRC Email:

Year in School: School District:

Diagnosis:

Functional Limitations: (please explain)

Communication:

Mobility:

Self-Direction:

Work Skills:

Interpersonal Skills:

Work Tolerance:

Self Care:

Environmental Conditions:

Accommodations/Assistive Technology Devices: (please list any accommodation needs known and any assistive technology devices used, proficiency with devices 1=minimal 5=outstanding and if they are allowed to use them over the summer.):

Travel Training:

Student can accurately and independently gather travel information? Yes No Unsure

Can the student travel on public transportation independently? Yes No Unsure

Describe the student’s community travel skills (include intersections-stop signs, lighted intersections, street crossing, etc.):

Computer Skills: Please list all devices student has knowledge of using. Please rate proficiency on a scale of 1-5, 1=minimal competency, 5= outstanding competency

1 2 3 4 5

 Use of internet
 Use of email
 Word Processing
 Excel
 Powerpoint
 MS Access, Quickbooks, etc
 Keyboarding
 Other: Please List:

Students Top Three Strengths:

Student’s Job Interest Areas: (In Order of Interest):

Student’s Skill Interest Areas:

Below are tasks that the student may be asked to do during their summer work experience. Please check ALL tasks they may be interested in:

Speaking/interacting with customers Caring for animals (Ex: doggie daycare)

Caring for children/infants Receiving/processing money/customer payments

Providing information to customers Working in the great outdoors

Stocking/moving items Preparing/serving hot or cold beverages

Working with hands/physical labor Computer work/office administration

Teaching/Mentoring others Design, art, engineering or the desire to create

Landscaping tasks Presenting in front of a group

Preparing/serving food/snacks Cleaning/organizing

Other: ______

Volunteer and Work Experience

Has the student had any in-school work experiences? Any volunteer or paid work in the community? If so, please list tasks preformed:

Daily Living Skills:

Independent / Needs Cues or Assistance / Not at all
Makes Bed
Picks up clothing
Fold/put away laundry
Clean/maintain tidy bedroom
Sweeping
Mopping
Wiping Surfaces
Vacuuming
Emptying trashcans
Washing Dishes
Separates laundry
Operates Machine
Does laundry
Cook more than a 3 ingredient recipe
Operate microwave
Operate Range/Oven
Cleanup of materials
Cleanup of used surfaces
Tooth brushing
Hair Care
Hygiene needs
Interacts appropriately with peers
Interacts appropriately with adults
Attentive &respectful during meetings/classes
Has ability to budget money
Has a bank account (circle yes or no) / Yes / No
Can independently negotiate bank teller experience
Has knowledge of local public transportation

Other Information you would like us to know: