New Project SEARCH® Arkansas: ACCESS Initiative Application

Project SEARCH® Arkansas: ACCESS Initiative Application - Adult Program

Program Information

To which program location are you applying?

Any Questions?

If you have questions or concerns about the application, please call Rebekah Seljan at (501) 515-2691.

PERSONAL DATA

Applicant Contact Information

If you do not have an email address, please provide the email of a parent or guardian.

First name

Preferred Name

Middle Name

Last name

Intern Birth Date

MUST be 18 by program start date.

Gender

Ethnicity

Social Security Number

Resides with

Primary Phone

Alternate Phone

Address

City

State/Province

Zip/Postcode

County

Parent Contact Information

Parent 1 First Name

Parent 1 Preferred Name

Parent 1 Last Name

Parent 1 Primary Phone

Parent 1 Alternate Phone

Parent 1 Email

Parent 1 Street

Parent 1 City

Parent 1 State

Parent 1 Zip Code

Parent 2 First Name

Parent 2 Preferred Name

Parent 2 Last Name

Parent 2 Primary Phone

Parent 2 Alternate Phone

Parent 2 Email

Parent 2 Street

Parent 2 City

Parent 2 State

Parent 2 Zip Code

Guardian Contact Information

Own guardian

You will be required to provide legal documentation of guardianship if you are accepted into the program.

Guardian 1 Legal Documentation of Guardianship

Guardian 1 Preferred Name

Guardian 1 Last Name

Guardian 1 Primary Phone

Guardian 1 Alternate Phone

Address

City

State/Province

Zip/Postcode

Funding Information

Benefits Received: SSI

Yes No Not Selected

Benefits Received: SSDI

Yes No Not Selected

Benefits Received: ACS-HCBS (Medicaid) Waiver

Yes No Not Selected

Do you have an Arkansas Rehabilitation Services Vocational Rehabilitation Counselor?

Yes No Not Selected

Current Rehab Counselor Name

If other, please provide name

Current Rehab Counselor Phone

Education Background

Have you Graduated from High School?

Yes No Not Selected

If you have graduated from high school please complete this section

High School Graduated from

High School Graduation Date

What type of Degree did you receive?

Date Completed

If you have not graduated from high school then please complete this section

What High School are you currently attending?

Estimated Graduation Date

What type of Degree will you be receiving?

Other Education/Program

Date Completed

Work Background

List jobs (paid or unpaid) you currently do or have done in school or in the community

Employer # 1

Job Title

Job Duties 1

Job Duties 2

Job Duties 3

Supervisor Name

Supervisor Phone

Paid/Unpaid:

Begin Date

End Date

Fired?

Yes No Not Selected

If yes, please explain

Quit?

Yes No Not Selected

Explain Reason for Leaving

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Employer # 2

Job Title

Job Duties 1

Job Duties 2

Job Duties 3

Supervisor Name

Supervisor Phone

Paid/Unpaid:

Begin Date

End Date

Fired?

Yes No Not Selected

If yes, please explain

Quit?

Yes No Not Selected

Explain Reason for Leaving

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Employer # 3

Job Title

Job Duties 1

Job Duties 2

Job Duties 3

Supervisor Name

Supervisor Phone

Paid/Unpaid:

Begin Date

End Date

Fired?

Yes No Not Selected

If yes, please explain

Quit?

Yes No Not Selected

Explain Reason for Leaving

Transportation

How do you plan to get to your Project SEARCH program location?

Mode of Transportation

If other, please specify

Diagnosis

Primary Diagnosis

Additional disability, mental health conditions or medical conditions.

Secondary Diagnosis

Diagnosis 3

Diagnosis 4

Diagnosis 5

Diagnosis 6

If 'other" was selected for any above diagnosis, please list the specific diagnosis in the Comment Box below.

Diagnosis Comments

Additional Data

Why do you want to participate in the Project SEARCH program?

How did you hear about Project SEARCH Arkansas: ACCESS Initiative?

If other, please specify

Reference Information

Please provide the name and contact information of a non-related individual to complete an applicant assessment. (Example: previous employer, teacher, neighbor, etc.)

Reference First Name

Reference Last Name

Reference Phone Number

Reference Email

Application Compliance

Applicant's position within the program is contingent upon adherence to the policies and procedures of Project SEARCH Arkansas: ACCESS Initiative. By signing, the applicant and/or guardian agree to comply.

Representatives of ACCESS Group, Inc. have my permission to share my information with designated representatives of Arkansas Rehabilitation Services (ARS) during the application/selection process, and if selected during my participation in the training, employment planning, and follow-along services.

Applicant's Signature

Date

Legal Guardian Signature

Date

Did anyone help you complete this application?

Yes No Not Selected

Name of Individual

Relationship

Phone Number

Terms and Conditions

* I understand that if I am accepted into the Project Search Arkansas: ACCESS Initiative Program, I must abide by the following terms and conditions:

* I understand that the Project SEARCH program is a nine-month work/educational program, and I will actively pursue competitive employment when I have completed the program.

* I will complete at least three unpaid intern rotations at a Project SEARCH program location.

* I will attend the program every day as scheduled.

* I understand that the Project SEARCH program correlates with the ACCESS Academy academic calendar.

* I will dress appropriately and wear required attire.

*I will call my instructor when I will be absent or tardy.

*I understand that I am responsible for transportation to and from my Project SEARCH program location.

* I will follow all rules established by the program.

* I will attend and be an active participant at meetings with my rehabilitation counselor, parents, instructors and staff.

. * I will be up to date on all needed immunizations.

. * I will be able to pass a felony background check.

* I will receive a TB Skin Test and Flu Shot.

* I will remain drug and nicotine free through out the program.

I have read the above terms and conditions and agree with what has been stated. I understand that I may be asked to leave the Project SEARCH program if I fail to follow the terms and conditions.