New Project SEARCH® Arkansas: ACCESS Initiative Application

Project SEARCH® Arkansas: ACCESS Initiative Application - High School Program

Program Information

To which program location are you applying?

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 Preferred Name

Guardian 1 Last Name

Guardian 1 Middle 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

Education Background

What High School are you currently attending?

If you are currently a Senior, have you completed all high school credits necessary for graduation?

Yes No Not Selected

Please read the following statements and answer whether you understand them

Do you understand that this will be your last year of student services and will accept your high school diploma at the end of the program year?

Yes No Not Selected

Do you understand that if you quit the program early you will immediately receive your high school diploma and cannot return to high school to receive student services?

Yes No Not Selected

Do you understand if you are dismissed from the program for disciplinary reasons you will immediately receive your high school diploma and cannot return to high school to receive student services?

Yes No Not Selected

Work Background

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

----------

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

---------

Have you ever been convicted of any crime?

Yes No Not Selected

If yes, what was the crime?

After the program is complete, do you plan on getting and maintaining job?

Yes No Not Selected

Transportation

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

Mode of Transportation

If other, please specify

Diagnosis/Symptons

Primary Diagnosis

Secondary Diagnosis

Diagnosis 3

Diagnosis 4

Diagnosis 5

Diagnosis 6

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 Inititive. By signing, the applicant and/or guardian agree to comply

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 during the Project SEARCH program.

* I will attend the program every day as scheduled.

* I understand that the Project SEARCH program correlates with the school district academic calendar.

* I will dress appropriately and wear required attire.

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

*I understand that I am responsible for transportation to and from my Project SEARCH 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 criminal background check.

* I will receive a T.SPOT.TB blood test for tuberculosis and Flu Shot.

* I will receive a drug screen prior to the start of the program and for cause or incident during 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.