Application Purpose & Guidelines



[pic]

[pic] [pic]

| | |

| | |

|Name | |

|School | |

Completed packets must be received/postmarked by: 3/15/19 via mail, fax or email

Mail to and for Additional Information:

Melissa Hosey, EC Coordinator

134 Franklin Boulevard

Greensboro, NC 27401

336-370-2323

Fax to: Melissa Hosey 336-370-2326

Email to: 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

Application Packet- (completed by the student and/or parent/guardian- you may ask for

assistance from your child's teacher)

Teacher Assessment- (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 Requirements

Students who are selected for the Project SEARCH program must 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, and if necessary;

• receive the flu shot required when they become available in fall and

• receive additional immunizations required by the host employer before the student may start the program on August 26, 2019 .

The Project SEARCH partners will assist each selected student to get their immunization records completed, and to get a background and criminal record check done. 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 hospital during the month of October.

Selection Criteria

1. Students who desire to work competitively for a least 16 hours a week at the end of the Project SEARCH internship program.

2. Students who are at least 18 to 22 years of age and have an IEP.

3. Students with an Intellectual or Developmental Disability that impacts employment.

4. 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 & Schedule

➢ February 26h: Parent Information Session

Interested applicants are strongly encouraged to attend this information session.

When: 6:00pm – 7:00pm

Where: Western Guilford High School, 409 Friendway Rd Greensboro, NC

Directions: The media center is located in the main building down the hallway to the left upon entering the building. Parking is available directly in front of the building.

➢ March 6th: Lunch & Learn @ HP Hospital 12:00pm – 1:00pm

600 N Elm St. High Point; bring your lunch or just drop in to hear about Project SEARCH.

➢ March 7th: Lunch & Learn @ Moses Cone Hospital 12:00pm – 1:00pm

1200 N Elm St. Greensboro; bring your lunch or just drop in to hear about Project SEARCH.

➢ March 15th: Applications Due

➢ March 26th and 27th: 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.

➢ On or Before April 12th: 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:

• High Point Regional UNC Health Care

• Moses H Cone Memorial Hospital

• Guilford County Schools

• Sandhills Center

• UNC TEACCH Autism Program

• The Arc of Greensboro, Inc.

• North Carolina Division of Vocational Rehabilition

Application Information

|A. |PERSONAL DATA |

|Name |      |      |      |

| |Last |First |Middle |

| |

|Address: |      |      |      |

| |Street |City |Zip Code |

| |

|High School Attended: | | | |

| | |Years of High School Completed: | |

| |

| |

| |

|Adapted Curriculum: Yes N |

|Occupational Course of Study: Yes No: |

| |

| |

|Current Diagnoses:___________________________________________________________________ |

|(Documentation of your Intellectual/Developmental Disability and/or Autism Spectrum Disorder) |

| | | | | |

| | | | | |

| | | | | |

|Male Female (optional) | | | | |

| | | | | |

|Birth Date: __________________ | | | | |

|Parent/Guardian Name: |      |Parent/Guardian e-mail: |      |

| |

|Address: |      | |      |      |

| |Street |City |Zip Code |

| |

|Home Phone: |      |

|Work Phone: |      |

|Cell Phone: |      |

|B. PARENT/GUARDIAN/STUDENT INFORMATION |

|1. 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, High Point UNC Health System, Friends Homes, Inc. 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. |

| |

| |

|The person assisting the student in completing this application is: |

| |

| |

| |

| |

| |

| |

|Name |

|Title |

|Phone Number |

| |

| |

| |

| |

|Email |

| |

| | | |

C. FUTURE EMPLOYMENT PREFERENCES and BACKGROUND:

How do you want to be employed in the community upon completion of Project SEARCH?

|Full time | |Part time | |

Which shift would you prefer working after graduating from Project SEARCH?

|1st Shift | |2nd Shift | |3rd Shift | |

Would you be willing to work holidays and/or weekends?

|Yes | | No | |

Do you currently have paid employment?

|Yes | | No | |

|If yes where? |      |How many days/ hours? |      |

List jobs/volunteer opportunities you do or have done in school or in the community:

|Employer & Dates of |Job Title/Duties |Supervisor Name |Contact Number |Paid |Unpaid |

|employment | | | | |(volunteer) |

|      |      |      |      | | |

|      |      |      |      | | |

|      |      |      |      | | |

|      |      |      |      | | |

Have you ever been fired from a job?

|Yes | | No | |

If yes, please explain:     _____________________________________________________________

|      |

Have you ever quit a job?

|Yes | | No | |

If yes, please explain:     _____________________________________________________________

|      |

Is there a reason why you would not pass a required Back Ground Check?

|Yes | | No | |

If yes, please explain:     _____________________________________________________________

|      |

D. SERVICE AGENCIES

I am currently receiving CAP/C, CAP/DA or Innovations Waiver services

YES or NO

Do you currently have a Vocational Rehabilitation counselor or have you had a vocational rehabilitation counselor in the past?

|Yes | |Name |      |Phone Number: |      |

|No | |

Are you currently receiving a stipend payment from VR?

|Yes No I don’t know | |

Are you eligible for services from Sandhills Center?

|Yes No I don’t know | |

Do you currently have or have you had a case manager, care coordinator or community guide in the past?

|Yes No I don’t know | | | | | |

| | | | | | |

| | | | | | |

|Name: | | | | | |

|      | | | | | |

|Phone Number: | | | | | |

|      | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

|Are you involved with any other agency service provider(s)? | |

|Yes No I don’t know | |

| | |

| | |

|Name: | |

|      | |

|Phone Numbe | |

|: | |

|      | |

| | |

| | |

| | |

| | |

E. INDEPENDENT LIVING

Please list any health or medical issues that might impact your employment or internship experience?

|      |

|      |

Please list any personal care or hygiene issues that might impact your employment or internship experience?

|      |

|      |

Please list any other limitations that may impact your employment or internship experience (transportation, etc.)

|      |

|      |

Do you need any accommodations in order to have a successful internship experience?

|Yes | | No | |

| | | | |

If you answered yes, to the question above, what supports do you have in place already?

Please Explain:

|      |

|      |

|      |

Do you use any of the following forms of transportation?

City Bus:

|Yes | | No | |

| | | | |

Specialized Transportation (SCAT, High-Tran, Dial-A-Lift)

|Yes | | No | |

Other: Please Explain:

|      |

|      |

|      |

F. STUDENT RESPONSE QUESTION

Why 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.)

|      |

|      |

|      |

|      |

|      |

|      |

|      |

G. REFERENCES

| |Name |Type of Reference |Phone Number |Email Address |

|1. |      |Personal Reference |      |      |

| | | | | |

| | | | | |

|2. |      |Personal Reference |      |      |

| | | | | |

| | | | | |

|3. |      |Other Community or Agency |      |      |

| | |Reference | | |

| | | | | |

For additional information or questions you may contact:

Melissa Hosey, EC Coordinator

336-370-2323

Email to: hoseym@

Student and Parent Contract for Project SEARCH Application

Read 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, submit to a TB skin test before entering the Project SEARCH program and 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 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 and parent/guardian have read and understand the above terms and conditions. We understand that if the intern 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.

____________________________________ ____________________________

Student Signature Date

___________________________________ ____________________________

Parent/Guardian Signature Date

Please use these blank pages if needed for extra comments:

[pic][pic]

-----------------------

Application for Adssion (page 4 of 5

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download