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center0 INCLUDEPICTURE "" \* MERGEFORMATINET NameSchool Completed packets must be received/postmarked by: 3/06/20 via mail, fax or email Mail to and for Additional Information:Melissa Hosey, EC Coordinator134 Franklin BoulevardGreensboro, NC 27401336-370-2323Fax to: Melissa Hosey 336-370-2326Email to: HYPERLINK "mailto:abourjk@" hoseym@*PLEASE NOTE*ALL THE REQUIRED DOCUMENTS MUST BE COMPLETED AND Submitted TOGETHER FOR CONSIDERATION - You may ask your child’s teacher to assist you with completion of the application FORMCHECKBOX Application Packet- (completed by the student and/or parent/guardian- you may ask for assistance from your child's teacher) FORMCHECKBOX Teacher Assessment Parts A & B - (completed by the separate class teacher)Date Received (official use only) _______________This application is one part that enables the Project SEARCH Selection Committee to gather information on each student candidate’s skills, abilities and background. A parent, student, counselor, teacher or employer may be contacted to gather additional information. The committee strives to select students who will be successful in the Project SEARCH program and who will reach the ultimate outcome of competitive employment.Program RequirementsStudents who are selected for Project Search must become clients of Vocational Rehabilitation.Students who are selected for the Project SEARCH program must also be able to:pass a criminal background check (including fingerprinting),pass a drug screen,provide proof of required immunization records, submit to a TB test;receive the flu shot required when they become available in fall;receive additional immunizations required by the host employer before the programs begins on August 24, 2020. The Project SEARCH partners will assist each selected student in completing immunization records and obtaining background and criminal records. Immunization records must also be submitted before a student begins Project SEARCH and all immunizations must be up to date. A flu shot will be administered by the hospitals in the fall. Selection CriteriaStudents who desire to work competitively for a least 16 hours a week at the end of the Project SEARCH internship program.Students who are at least 18 to 22 years of age and have an IEP.Students with an Intellectual or Developmental Disability that impacts employment.Students who will benefit from participation in a variety of internships. Please note: Students who currently receive Innovations Waiver services including CAP/C (Community Alternative Program – Children) CAP/DA (Community Alternative Program/Disabled Adult) may be eligible for funding for Project Search. Priority given to eligible students without other funding resources.Selection Process & ScheduleFebruary 4 and 25: Parent Information SessionsInterested applicants are strongly encouraged to attend this information session.When: 6:00pm – 7:00pm Where: Western Guilford High School, 409 Friendway Rd., Greensboro, NCDirections: The media center is in the main building. Take center entrance into the lobby and turn left before the office. Parking is available directly in front of the building. February 18: Lunch & Learn @ Moses Cone 12:00pm – 1:00pm1200 N Elm St. Greensboro; bring your lunch or just drop in to learn more about Project SEARCHFebruary 19: Lunch & Learn @ High Point Medical Center 12:00pm – 1:00pm600 N Elm St. High Point; bring your lunch or just drop in to learn more about Project SEARCHFebruary 25: Parent Information Session – details aboveMarch 6: Applications Due March 24th and 25th: Student Interviews Students who are chosen for interviews will be given a date and time for an interview that will include a working interview. Interviews will be held at the Jamestown United Methodist Church Oakdale Campus located at 532 Oakdale Road, Jamestown, NC 27282 between 9am and 4pm. April 15: Letter of Acceptance A letter will be sent to each student indicating whether they are accepted into the Project SEARCH program.Selection Committee*The Selection Committee will include representatives from:Wake Forest Baptist Health - High Point Medical CenterMoses H Cone Memorial HospitalGuilford County SchoolsSandhills Center UNC TEACCH Autism ProgramThe Arc of Greensboro, Inc.North Carolina Division of Vocational RehabilitationApplication InformationA.PERSONAL DATAName FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LastFirstMiddleAddress: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????StreetCityZip CodeHigh School Attended:Years of High School Completed: Adapted Curriculum: Yes FORMCHECKBOX No FORMCHECKBOX Occupational Course of Study: Yes FORMCHECKBOX No: FORMCHECKBOX Current Diagnoses: ________________________________________________________________ (Documentation of your Intellectual/Developmental Disability and/or Autism Spectrum Disorder)Male FORMCHECKBOX Female FORMCHECKBOX (optional)Birth Date: __________________Parent/Guardian Name: _______ FORMTEXT ?????Parent/Guardian e-mail: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????StreetCityZip CodeHome Phone: FORMTEXT ?????Work Phone: FORMTEXT ?????Cell Phone: FORMTEXT ?????B. PARENT/GUARDIAN/STUDENT INFORMATION1. Release: You will be required to sign a release of information concerning your son/daughter that will be shared with Sandhills Center, The Arc of Greensboro, Inc., UNC TEACCH Autism Program, Moses Cone Hospital, High Point Medical Center and NC Vocational Rehabilitation, as appropriate.2. Disclaimer: In compliance with federal laws, Guilford County Schools administers all educational programs, employment activities, religion, national or ethnic origin, color, age, military service, disability or gender, except where appropriate and allowed by law. Refer to the Board of Education Discrimination Free Environment Policy AC for a complete statement. Inquiries or complaints should be directed to the Guilford County Schools Compliance Officer 120 Franklin Boulevard, Greensboro, NC 27401:336-370-2323.3. GuardianshipStudent is their own guardian Yes FORMCHECKBOX No FORMCHECKBOX Parent has secured full guardianship through the court system. Yes FORMCHECKBOX No FORMCHECKBOX Parent has secured partial guardianship through the court system. Yes FORMCHECKBOX No FORMCHECKBOX The person assisting the student in completing this application is:NameTitle Phone NumberEmail EMPLOYMENT PREFERENCES and WORK EXPERIENCE:How do you want to be employed in the community upon completion of Project SEARCH? Full time FORMCHECKBOX Part time FORMCHECKBOX Which shift would you prefer working after graduating from Project SEARCH? 1st Shift FORMCHECKBOX 2nd Shift FORMCHECKBOX 3rd Shift FORMCHECKBOX Would you be willing to work holidays and/or weekends?Yes FORMCHECKBOX No FORMCHECKBOX Do you currently have paid employment? Yes FORMCHECKBOX No FORMCHECKBOX If yes where? FORMTEXT ?????How many days/ hours? FORMTEXT ?????List jobs and/or volunteer opportunities you do in the community – not school related: Employer & Dates of employmentJob Title/DutiesSupervisor NameContact NumberPaidUnpaid(volunteer) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Have you ever been fired from a job? Yes FORMCHECKBOX No FORMCHECKBOX If yes, please explain: FORMTEXT ?????_____________________________________________________________ FORMTEXT ?????Have you ever quit a job? Yes FORMCHECKBOX No FORMCHECKBOX If yes, please explain: FORMTEXT ?????_____________________________________________________________ FORMTEXT ?????-82804019685Application for Adssion (page 4 of 500Application for Adssion (page 4 of 5Is there a reason why you would not pass a required background Check?Yes FORMCHECKBOX No FORMCHECKBOX If yes, please explain: FORMTEXT ?????_____________________________________________________________ FORMTEXT ?????D. SERVICE AGENCIESI am currently receiving CAP/C, CAP/DA or Innovations Waiver servicesYes FORMCHECKBOX or NO FORMCHECKBOX Do you currently have a Vocational Rehabilitation counselor or have you had a vocational rehabilitation counselor in the past?Yes FORMCHECKBOX Name FORMTEXT ????? Phone Number: FORMTEXT ?????No FORMCHECKBOX Are you currently receiving a stipend payment from VR? Yes FORMCHECKBOX No FORMCHECKBOX I don’t know FORMCHECKBOX Are you eligible for services from Sandhills Center? Yes FORMCHECKBOX No FORMCHECKBOX I don’t know FORMCHECKBOX Do you currently have or have you had a case manager, care coordinator or community guide in the past?Yes FORMCHECKBOX No FORMCHECKBOX I don’t know FORMCHECKBOX Name: FORMTEXT ?????Phone Number: FORMTEXT ?????Are you involved with any other agency / social service provider(s)?Yes FORMCHECKBOX No FORMCHECKBOX I don’t know FORMCHECKBOX Name: FORMTEXT ?????Phone Number: FORMTEXT ?????E. INDEPENDENT LIVINGPlease list any health or medical issues that might impact your employment or internship experience? FORMTEXT ????? FORMTEXT ?????Please list any personal care or hygiene issues that might impact your employment or internship experience? FORMTEXT ????? FORMTEXT ?????Please list any other limitations that may impact your employment or internship experience (transportation, etc.) FORMTEXT ????? FORMTEXT ?????Do you need any accommodations in place to have a successful internship experience? Yes FORMCHECKBOX No FORMCHECKBOX If you answered yes, to the question above, what supports do you have in place already?Please Explain: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you use any of the following forms of transportation?City Bus: Yes FORMCHECKBOX No FORMCHECKBOX Specialized Transportation (SCAT, Guilford Transportation & Mobility, High-Tran, Dial-A-Lift) Yes FORMCHECKBOX No FORMCHECKBOX Will family support you in learning to use any of the following forms of transportation?City Bus: Yes FORMCHECKBOX No FORMCHECKBOX Specialized Transportation (SCAT, Guilford Transportation & Mobility, High-Tran, Dial-A-Lift) Yes FORMCHECKBOX No FORMCHECKBOX Other transportation issues or concerns: Please Explain: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????F. STUDENT RESPONSE QUESTIONWhy do you want to participate in Project SEARCH? (Complete in your own words; you may have a person assist you with writing your response if needed.) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????G. REFERENCES NameType of ReferencePhone NumberEmail Address1. FORMTEXT ?????Personal Reference FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ?????Personal Reference FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ?????Other Community or Agency Reference FORMTEXT ????? FORMTEXT ?????Disclaimer: In compliance with federal laws, Guilford County Schools administers all educational programs, employment activities, religion, national or ethnic origin, color, age, military service, disability or gender, except where appropriate and allowed by law. Refer to the Board of Education Discrimination Free Environment Policy AC for a complete statement. Inquiries or complaints should be directed to the Guilford County Schools Compliance Officer 120 Franklin Boulevard, Greensboro, NC 27401:336-370-2323.For additional information or questions you may contact:Melissa Hosey, EC Coordinator336-370-2323 Email to: hoseym@ Student and Parent Contract for Project SEARCH ApplicationRead the contract below and sign and date. Acceptance into the Project SEARCH program requires the following terms and conditions.I will complete three (10 week) UNPAID internship rotations.I will actively work with Vocational Rehabilitation to obtain services.I will actively pursue employment at the end of the internship with the support of either TEACCH or Arc of Greensboro. I understand employment at the host site is not guaranteed.I understand that I am required to pass a criminal background check and drug screen before I enter the Project SEARCH program. I also must produce a complete immunization record and submit to a TB test before entering the Project SEARCH program. I must also get a flu shot when available during the fall. I will be given assistance to get these completed.I will adhere to the attendance policy established by the Project SEARCH program.I will follow the Project SEARCH calendar given to me at the beginning of the year.I will follow the dress code and maintain appropriate hygiene.I understand that transportation to the host site is based on my current IEP.I am willing to learn to use and will utilize public transportation when available.I will follow all the rules established by the program, host business and Guilford County Schools.I will attend required meetings with my teachers, job coaches, parents and vocational rehabilitation counselor.I will be an active participant and communicate any issues at our required meetings.Intern has read and agrees to the above terms and conditions. I understand that if I fail to comply with these terms and conditions, I may be asked to leave the Project SEARCH program at any time and return to assigned school when appropriate.____________________________________ ____________________________ Student Signature DateParent/guardian has read and understands the above terms and conditions as required for the intern. I understand that if the intern fails to fails to comply with these terms and conditions, the intern may be asked to leave the Project SEARCH program at any time and return to assigned school when appropriate.__________________________________ ____________________________ Parent/Guardian Signature DatePlease use these blank pages if needed for extra comments: ................
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