REFERRAL FOR MICHIGAN JOBS COMMISSION - MICHIGAN ...
REFERRAL FOR MICHIGAN DEPTARTMENT OF ENERGY,
LABOR AND ECONOMIC GROWTH
MICHIGAN REHABILITATION SERVICES (MRS)
Michigan Rehabilitation Services (MRS) provides the opportunity for thousands of citizens with handicaps to become independent through employment. Almost any type of disability could qualify an individual for MRS assistance as long as it INTERFERES WITH EMPLOYMENT and that there is reasonable expectation that the student meet employment outcomes and will become gainfully employed.
Listed are a few of the disabilities that could qualify an individual:
-Speech impairment -Epilepsy -Visual impairment
-Emotional problem -Cerebral palsy -Mental impairment
-Spinal cord injury -Learning disability -Kidney disease
-Substance abuse -Loss of limb(s) -Hearing loss
-Cancer -Heart diseases -And many others
DATE OF REFERRAL: ______________________ TYPE OF REFERRAL: SPECIAL EDUCATION ___ 504 ___
STUDENT: ________________________________ BIRTH DATE: ____________________________
SEX: M___ F___ GRADE: ______________ SOCIAL SECURITY NUMBER ___________________________
(Not to be completed by the School District – MRS will obtain)
HOME ADDRESS: ____________________________ CITY: _____________________________ ZIP: _______________
SCHOOL DISTRICT: ___________________________ SCHOOL: _____________________________________________
PARENT(S) OR GUARDIAN: _______________________________________________________________________
ADDRESS, IF DIFFERENT: ________________________________________________________________________
HOME TELEPHONE: (____) _____________________________ DISABILITY: ______________________________
REFERRED BY: ______________________________________ TITLE: _____________________________________
CAREER CENTER PROGRAM: _______________________________ A.M. ___________ P.M. ________________
WAS MRS DISCUSSED WITH STUDENT ____________________________________________________________
READING GRADE LEVEL: ______________________________ MATH GRADE LEVEL: _____________________
ATTACHMENTS/ADDITIONAL INFORMATION
IEPT, DATE: _____________ MEDICAL: ____________
MET, DATE: ______________ HEARING: ____________
PSYCHOLOGICAL, DATE: __________ VISION: ______________
SOCIAL WORKER EVALUATION, DATE: _______________ OTHER: ______________
ROI 9 INTERAGENCY AUTHORIZATION TO INVITE ______________ EDP: __________________
***THIS FORM AND THE ABOVE MENTIONED ATTACHMENTS SHOULD BE SUBMITTED TO THE ATTENTION OF MRS
REPRESENTIVE AT THE SANILAC CAREER CENTER
-----------------------
[pic]
Special Education Services
46 North Jackson Street
Sandusky, Michigan 48471
810-648-2200
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