VCU ACE IT in College Application 2019



ApplicationFall 2019Name: FORMTEXT ?????Date Received (official use only): FORMTEXT ?????Virginia Commonwealth University’s ACE-IT in College program is an inclusive college experience for individuals with intellectual disabilities/developmental disabilities. One purpose of this program is to learn about the experiences of students with intellectual disabilities in college. It is understood by submitting this application that ACE-IT in College staff will be collecting information on student progress in classes, time spent with supports, work and internship participation, and outcomes achieved after receiving the Certificate of Completion.ACE-IT is designed to: serve students with I/DD and provide individual supports and services for their full participation in courses and employment;focus on students’ academic enrichment, social and interpersonal skills, independent living skills, including self-advocacy, and integrated work experiences and career skills that lead to competitive employment; andintegrate person-centered planning in the development of each student’s course of study and career exploration activities.The purpose of this application packet is to provide information to the VCU ACE-IT in College Selection Committee regarding each applicant’s skills, abilities, interests, and experience. The Selection Committee may contact the applicant, a family member, case manager, employer, or reference to gather additional information as needed. Our final goal is to select prospective students who will be successful in college, earn a certificate from VCU, and reach the outcome of integrated competitive employment in the career of their choice.Application Packet ChecklistPlease return the application and all supporting documentation by March 1st, 2019 to:Hard Copy to: ACE-IT in CollegeVCU RRTC1314 West Main Street P.O. Box 842011 Richmond, VA 23284Electronic Copy to:aceit@vcu.eduWith the words “Application Packet” in the subject line.Applications that are incomplete or missing any documentation will not be considered. Completed application packet (Pages 6-23)Current student resumeMost recent Transition Individualized Education Program (IEP), Individualized Service Plan (ISP), Individualized Plan for Employment (IPE), OR any combination of the three. Documentation from most recent eligibility determination with specified disability diagnosis or psychoeducational testing results High school transcriptHigh school attendance record and disciplinary recordResults career and/ or transition assessments (if available)Three reference completed and submitted by individuals as indicated on each formIf you have questions or require an accessible application form, please contact aceit@vcu.eduVCU ACE-IT in College Selection CriteriaEligible applicants for the Fall 2019 ACE-IT in College cohort will:Be between 18-26 years of age at the time of application.Expect to pay tuition and fees for the 20+ credit certificate program (dependent upon number of classes, cost of books, meal plans, etc.). Per VCU policy, student accounts must be paid in full each semester in order to register for the next semester. Have a documented intellectual disability, traumatic brain injury, autism, or multiple disabilities as defined by the Virginia Department of Education’s Special Education Regulations 8VAC20-81-10 and be willing to provide documentation with the application packet. Have completed or will complete high school prior to program entry with a Modified Standard Diploma, Applied Studies or Special Diploma, or Certificate of Program Completion.Have an interest in going to college as a non-degree seeking student to expand career opportunities and earn a certificate awarded through VCU’s School of Education. Be able to commit to a 20+ credit hour program, taking 4 – 6 credit hours per week of classes.Agree to follow VCU’s Student Code of Conduct in class and in the community.Understand that acceptance into VCU ACE-IT in College is not the same as being accepted into VCU as a degree- seeking student. ACE-IT students take courses for audit, meaning that there are no letter grades or college credit awarded. ACE-IT students earn a Certificate of Completion, not a diploma or degree. Courses taken cannot be transferred for credit to a 2 or 4 year degree. Have experience in a work environment (school, volunteer, and/or paid work).Participate in on campus part-time employment throughout the entire program. Establish goals leading to competitive employment upon completion of the ACE-IT certificate.Have experience independently using a clock and calendar to plan activities and care for self and belongings. Be willing to learn to independently navigate an urban college campus and to manage their own time between activities. Have experience using and maintaining their own cell phone and email to communicate with others in a timely fashion. Be willing to learn to communicate with program staff, professors, and peers on their own behalf.Agree to listen and respond to directions from an instructor, education coach, advisor, mentor, and work supervisor.Have experience attending and participating in classes for up to 50-90 minutes. Agree to study and meet with education coaches and others as needed on a weekly basis, to review classwork and discuss progress. Agree to utilize the support of a job coach throughout the program.Agree to complete all academic coursework as required by professors and instructors to the best of their ability throughout the program. Have or be prepared to arrange reliable, timely transportation to and from campus for all classes and other required activities. Pass a criminal background check for internship and employment sites. In order to maximize long term employment supports and success, we strongly encourage applicants to have an open case with the Department for Aging and Rehabilitative Services (DARS), have their DARS counselor’s support for attending ACE-IT in College, meet financial need, and have postsecondary education as a goal in their DARS Individualized Plan for Employment (IPE). VCU ACE-IT in College Application TimelineApplications DueMarch 1 2019Student Interviews(Panel and Campus Visit)March 2019Student SelectionMarch/April 2019Enrollment Paperwork DueApril 2019Person-Centered Planning MeetingsMay/June 2019OrientationJune/July 2019Classes BeginAugust 2019ACE-IT in College ApplicationTo be completed by individual (and family)Applicant Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LastFirstMiddleAddress: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????StreetCity/CountyZip CodeCounty/City of Residence: FORMTEXT ?????Email: FORMTEXT ?????Applicant Phone Number: FORMTEXT ?????Name of your High School: FORMTEXT ?????Date of Birth: FORMTEXT ?????Gender: FORMTEXT ?????Family Member Name: FORMTEXT ?????Family Member Email: FORMTEXT ?????Family Member Phone Number: FORMTEXT ?????Family Member Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????StreetCityZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Home PhoneCell PhoneWork PhoneHave you ever been convicted of a misdemeanor? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been convicted of a felony? FORMCHECKBOX Yes FORMCHECKBOX NoApplicant and Family InformationIf accepted into VCU ACE-IT in College, a Consent to Exchange Information form must be signed to share relevant information with participating agencies and businesses.If accepted into VCU ACE-IT in College, you must provide current documentation of your disability to VCU Student Accessibility and Educational Opportunity to request accommodations. A one semester probationary period will be required of all accepted students.Equal Opportunity: Acceptance will be made without regard to race, color, religion, national origin, age, gender, political affiliation, veterans’ status, sexual orientation, or disability.Applicant Signature: FORMTEXT ?????Date: FORMTEXT ?????Family Member Signature: FORMTEXT ?????Date: FORMTEXT ?????Educational ExperienceHigh school graduation year: FORMTEXT ?????Your diploma type: FORMCHECKBOX Modified Standard FORMCHECKBOX Certificate FORMCHECKBOX Applied Studies FORMCHECKBOX Other: FORMTEXT ?????Have you attended college or a training program before? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please answer the following:Name of Program? FORMTEXT ?????How Long? FORMTEXT ?????Completed the Program? FORMCHECKBOX Yes FORMCHECKBOX NoEmployment/Work ExperienceAre you currently employed? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, where? FORMTEXT ?????Will you maintain current employment during the academic semester(s), in addition to taking classes and participating in a campus job? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ADescribe two of your most recent jobs. If you have no paid work experiences, then describe volunteer work at school or in the community.Employment SiteJob DutiesDatesHours/WeekWas this a Paid Position? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoIf no longer employed, why did you leave your job(s)? FORMTEXT ?????Service AgenciesDo you receive services or supports from the following agencies?AgencyYes/NoCounselor or Case Manager NamePhone or email addressDepartment for Aging and Rehabilitative Services (DARS) FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ?????Employment Support Vendors (Job coach) FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ?????Community Services Board FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ?????I give permission to inform my service providers (DARS, CSB, Employment Support Vendor) that I am applying to ACE IT in College and to obtain information about my case: 28575235438 FORMTEXT ?????Signature FORMTEXT ?????19573203200Date Do you have a Medicaid Waiver? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please describe: FORMTEXT ?????Do you receive benefits from Social Security Administration? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please describe: FORMTEXT ?????Postsecondary GoalsList your desired postsecondary goals.Education (Example: What college classes interest you?): FORMTEXT ?????Employment (Example: What careers interest you?): FORMTEXT ?????Independent Living (Example: Where would you like to live? With whom?): FORMTEXT ?????Health/Medical InformationList any health or medical conditions that could impact the full and safe participation in VCU ACE-IT in College:1215900 FORMTEXT ?????02397940 FORMTEXT ?????02372980 FORMTEXT ?????Support SummaryDo you need any supports or accommodates, including positive behavioral supports, to be successful in the classroom, on campus, or on a job? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ?????1177800Support SystemList individuals in your life who will assist with making the VCU ACE-IT in College experience successful if you are admitted.1215900 FORMTEXT ?????02397940 FORMTEXT ?????02372980 FORMTEXT ?????Applicant Signature: FORMTEXT ?????Date: FORMTEXT ?????Applicant ContractRead the applicant contract below and sign and date.I, FORMTEXT ?????, understand that students in VCU ACE-IT in College must abide by the following terms and conditions:I am responsible for my own success at VCU, which includes using supports and accommodations.I am responsible for completing all schoolwork not finished during education coaching on my own time, with family support. I am responsible for holding paid campus employment. Campus employment may not always reflect my first choice. I will participate in a paid or unpaid internship.I must check and maintain my VCU Email and ACE-IT Blackboard every day. I must manage my own personal items, self-care, money, time, campus involvement, and transportation.I am responsible for the time I am on campus and not in class, coaching time, and campus employment. This means that there will be times during the school day where I am on my own.I am responsible for my own summer activities. ACE-IT provides class and campus job supports during the fall and spring semesters only.I must call, text, or email the appropriate individuals (staff, supports, instructor, supervisor) if I am going to miss class, work, or meetings.I will have and independently use a cellphone while at VCU.I will complete 20+ credits in the certificate program at VCU.I understand that my first semester is a probationary semester.I will follow my course schedule, attend classes, and complete course assignments to the best of my ability.I will apply for academic accommodations with the VCU office of Student Accessibility and Educational Opportunity.I will complete the Free Application for Federal Student Aid (FAFSA) each academic year. I understand that I am responsible for all tuition, fees, and related expenses.I will follow all rules and expectations established by VCU and ACE-IT in College.I will attend scheduled meetings with my advisor, education coaches, and program staff, and understand that I can invite others to participate in the meetings. I will be an active participant in these meetings and communicate my thoughts and ideas.I will actively pursue employment as part of the certificate program.I have read the above and understand that this program is voluntary and I must agree to these terms if I am accepted into VCU ACE-IT in College. I understand that I may be asked to leave the program if I fail to follow the terms and conditions.2811294241827002393950 FORMTEXT ????? FORMTEXT ?????Applicant SignatureDate2811294241827002393950 FORMTEXT ????? FORMTEXT ?????Family Member SignatureDateIdentification of Skills and Support NeedsTo be completed by the applicant and with support from others as needed. Please use the following scale to represent level of functioning in each section:(3) Student is independent, requires no support.(2) Student requires some support.(1) Student requires complete support.Applicant Name: FORMTEXT ?????Date: FORMTEXT ?????Individual helping applicant to complete form (if applicable): FORMTEXT ?????TransportationIndependent (provides own transportation via car, scooter, bike, walking)Current Level of Functioning: ? FORMTEXT ?Makes own transportation arrangementsCurrent Level of Functioning: ? FORMTEXT ?Routinely uses public transportationCurrent Level of Functioning: ? FORMTEXT ?Uses special transportation (Examples: CARE Van, Lyft, Uber)If yes, please describe: FORMTEXT ?????Current Level of Functioning: ? FORMTEXT ?4457700-12699Intentionally BlankIntentionally BlankFamily provides all transportationCurrent Level of Functioning: ? FORMTEXT ?Travel SkillsTravels in familiar settingsCurrent Level of Functioning: FORMTEXT ??Travels in unfamiliar settingsCurrent Level of Functioning: FORMTEXT ? ?Crosses streets safely Current Level of Functioning: ? FORMTEXT ?Uses public transportation Current Level of Functioning: ? FORMTEXT ?Orienting Skillsidentifies signscarries identificationasks for helpresponsible for possessionsuses caution with strangersreads mapsCurrent Level of Functioning: ? FORMTEXT ?Comments: FORMTEXT ?????Safety SkillsApplicant is alone at home and/or in the community for up to FORMTEXT ?? hours and displays age appropriate safety skillsCurrent Level of Functioning: ? FORMTEXT ?Uses phone to dial emergency or familiar numbersCurrent Level of Functioning: ? FORMTEXT ?Asks for assistance if in need of help or if lostCurrent Level of Functioning: ? FORMTEXT ?Is aware of basic responses to fire, accidents, inclement weather, and emergency alerts Current Level of Functioning: ? FORMTEXT ?Physical Mobility/Orientation/MovementPhysical mobilityCurrent Level of Functioning: ? FORMTEXT ?Navigates stairs, minor obstacles, classrooms, and campus groundsCurrent Level of Functioning: ? FORMTEXT ?Uses mobility device FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please describe: FORMTEXT ?????Other considerations (Example: Uses a personal assistant) FORMTEXT ?????Personal CareTakes responsibility for personal careCurrent Level of Functioning: ? FORMTEXT ?DressingDresses selfChooses appropriate clothesDresses appropriately for season/weather conditionsCurrent Level of Functioning: ? FORMTEXT ?Comments: FORMTEXT ?????HygieneBrushes teethBrushes/combs/styles hairSkin careShowers/ bathes as neededUses deodorant Washes hands with soap after using the restroomManages menstrual care, if applicableCurrent Level of Functioning: ? FORMTEXT ?Comments: ? FORMTEXT ?????Communication/BehaviorCommunicates with others verbally Current Level of Functioning: ? FORMTEXT ?If you choose 1 or 2, please describe how you typically communicate with others (examples: augmentative communication device, sign language, written prompts): FORMTEXT ?????Communicates with others in writingCurrent Level of Functioning: ? FORMTEXT ?If you choose 1 or 2, please describe how you typically communicate with others (examples: speech-to-text, family member or friend to assist): FORMTEXT ?????Engages in age-appropriate social interactions (Examples: conversation, texting, social media)Current Level of Functioning: ? FORMTEXT ?Appropriately deals with conflictCurrent Level of Functioning: ? FORMTEXT ?Knows difference between friends, acquaintances, and strangersCurrent Level of Functioning: ? FORMTEXT ?Demonstrates listening skills (Can retell an event or story)Current Level of Functioning: ? FORMTEXT ?Literacy/MathematicsReads at FORMTEXT ????? grade levelCurrent Level of Functioning: ? FORMTEXT ?Completed math at FORMTEXT ????? grade level Current Level of Functioning: ? FORMTEXT ?Uses basic addition / subtractionCurrent Level of Functioning: ? FORMTEXT ?Counts FORMTEXT ????? number of objects and/or identifies numbers to FORMTEXT ?????Current Level of Functioning: ? FORMTEXT ?Identifies coins and bills and/or can make change up to a dollarCurrent Level of Functioning: ? FORMTEXT ?Manages own saving/checking accountCurrent Level of Functioning: ? FORMTEXT ?Uses ATM, debit card/credit cardCurrent Level of Functioning: ? FORMTEXT ?Use of Assistive and Other TechnologyUses cell phone routinely for calls, scheduling, texting, etc.Current Level of Functioning: ? FORMTEXT ?Uses assistive technology on routine basis Please list any programs or devices: FORMTEXT ?????Current Level of Functioning: ? FORMTEXT ?Uses social media (Facebook, Twitter, email, etc.)Current Level of Functioning: ? FORMTEXT ?Uses computer, tablet, or similar device.Please list any devices: FORMTEXT ?????Current Level of Functioning: ? FORMTEXT ?Planning/SchedulingFollowing daily routinesshows up on timefinds meeting locationsadapts to changes in routinetells timeCurrent Level of Functioning: ? FORMTEXT ?Comments: FORMTEXT ?????Scheduling weekly activitiesuses a time management system (Examples: calendar, day planner, paper or electronic)Current Level of Functioning: ? FORMTEXT ?Preparing for leisure activitiesarranges own leisure activitieshandles logistics involved in planning an activityCurrent Level of Functioning: ? FORMTEXT ?Comments: FORMTEXT ?????Time managementplans homework timedoes homeworkplans for chores, meetings, leisure timearranges transportationCurrent Level of Functioning: ? FORMTEXT ?Comments: FORMTEXT ?????SocialSocial and Behavior Skillsintroduces selffollows instructionsaccepts criticism or consequencegets people’s attention appropriatelymakes requests appropriatelyCurrent Level of Functioning: ? FORMTEXT ?Comments: FORMTEXT ?????Flexibility/StressAdapts to change easilyCurrent Level of Functioning: ? FORMTEXT ?Willing to change behavior based on feedbackCurrent Level of Functioning: ? FORMTEXT ?Identifies and responds effectively to authority figures Current Level of Functioning: ? FORMTEXT ?Uses stress management strategiesCurrent Level of Functioning: ? FORMTEXT ?Health and SexualityAwareness of sexuality issuesAwareness of public vs. private activitiesCloses bathroom stall door Appropriate show of affectionCurrent Level of Functioning: ? FORMTEXT ?If you choose 1 or 2, please describe: FORMTEXT ?????Knowledge of general health concernsDisease transmission (i.e., covers mouth when sneezing/coughing, blows nose, etc.)Health concerns specific to disability (i.e., skin care, range of motion, positioning of weight)Manages medication (i.e., knows medication schedule, ability to swallow)Cares for minor injury and/ or illnessSeeks assistance for medical needsCurrent Level of Functioning: ? FORMTEXT ?If you choose 1 or 2, please describe: FORMTEXT ?????ReferencesList 3 references and have each complete the corresponding reference form:NameType of ReferencePhone NumberEmail Address FORMTEXT ?????Personal Reference (not a family member) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????School or Work Reference FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Current DARS Counselor FORMTEXT ????? FORMTEXT ?????DARS counselor reference is required for those with open cases. If you do not have a DARS counselor, please provide an additional school or work reference.The person assisting the student to complete this application is: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NameTitlePhone NumberDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Organization (if applicable)Phone NumberEmail Contact FORMTEXT ?????Applicant SignatureVCU ACE-IT in College: Personal Reference Form FORMTEXT ????? has applied for admission to ACE-IT in College at Virginia Commonwealth University. VCU and the program promotes a supported education model that provides individualized supports to students with intellectual disabilities seeking postsecondary education to enhance their skills for employment. This model provides opportunities for career development using person-centered approaches, enrollment in college courses, internships, and participation in typical college experiences. Please answer the following questions to the best of your ability and return the form to aceit@vcu.edu no later than 5:00 PM on March 1, 2019. 43752302161410Name: FORMTEXT ?????Relationship to applicant: FORMTEXT ?????459852323850Address: FORMTEXT ?????578485437030Email: FORMTEXT ?????Phone: FORMTEXT ?????4159251449303217545278280How long have you know the applicant and in what capacity? FORMTEXT ?????How do you feel the applicant would benefit from VCU ACE-IT in College? FORMTEXT ?????Describe the strengths that the applicant has that will make them a strong candidate for the VCU ACE-IT in College certificate program. Think in terms of character traits such as honest, considerate, and dependable as well as personal skills such as communication, ability to work as a team, and initiative. FORMTEXT ?????In your opinion, what kinds of supports would be most helpful for this applicant to succeed in the certificate program? FORMTEXT ?????Intentionally BlankVCU ACE-IT in College: School/Work Reference Form FORMTEXT ?????_____________________________ has applied for admission to ACE-IT in College at Virginia Commonwealth University. VCU and the program promotes a supported education model that provides individualized supports to students with intellectual disabilities seeking postsecondary education to enhance their skills for employment. This model provides opportunities for career development using person-centered approaches, enrollment in college courses, internships, and participation in typical college experiences. Please answer the following questions to the best of your ability and return the form to aceit@vcu.edu no later than 5:00 PM on March 1, 2019.43752302161410Name: FORMTEXT ?????Relationship to applicant: FORMTEXT ?????459852323850Address: FORMTEXT ?????578485437030Email: FORMTEXT ?????Phone: FORMTEXT ?????4159251449303217545278280How long have you know the applicant and in what capacity? FORMTEXT ?????How do you feel the applicant would benefit from VCU ACE-IT in College? FORMTEXT ?????Describe the strengths that the applicant has that will make them a strong candidate for the VCU ACE-IT in College certificate program. Think in terms of character traits such as honest, considerate, and dependable as well as personal skills such as communication, ability to work as a team, and initiative. FORMTEXT ?????In your opinion, what kinds of supports would be most helpful for this applicant to succeed in the certificate program? FORMTEXT ?????Intentionally BlankVCU ACE-IT in College: DARS Reference Form FORMTEXT ?????______________________________ has applied for admission to ACE-IT in College at Virginia Commonwealth University. VCU and the program promotes a supported education model that provides individualized supports to students with intellectual disabilities seeking postsecondary education to enhance their skills for employment. This model provides opportunities for career development using person-centered approaches, enrollment in college courses, internships, and participation in typical college experiences. Please answer the following questions to the best of your ability and return the form to aceit@vcu.edu no later than 5:00 PM on March 1, 2019.43752302161410Name: FORMTEXT ?????Relationship to applicant: FORMTEXT ?????459852323850Address: FORMTEXT ?????578485437030Email: FORMTEXT ?????Phone: FORMTEXT ?????4159251449303217545278280How long have you know the applicant and in what capacity? FORMTEXT ?????How do you feel the applicant would benefit from VCU ACE-IT in College? FORMTEXT ?????Describe the strengths that the applicant has that will make them a strong candidate for the VCU ACE-IT in College certificate program. Think in terms of character traits such as honest, considerate, and dependable as well as personal skills such as communication, ability to work as a team, and initiative. FORMTEXT ?????In your opinion, what kinds of supports would be most helpful for this applicant to succeed in the certificate program? FORMTEXT ?????Do you support this applicant in attending VCU ACE-IT in College? FORMCHECKBOX Yes FORMCHECKBOX NoWill DARS support the payment of milestones? FORMCHECKBOX Yes FORMCHECKBOX NoIf you have any questions regarding the program or the milestone agreement, please contact Jaclyn Camden at jlcamden2@vcu.edu.Intentionally Blank ................
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