ILS Mission Statement

Transcription

1 Independent Living Skills Program Application Packet Idaho School for the Deaf and the Blind ILS Mission Statement The Idaho School for the Deaf and the Blind Independent Living Skills Program is dedicated to support deaf or hard of hearing young adults to attain foundational skills, training, and experiences to become responsible, contributing, independent adults in their communities. Idaho School for the Deaf and the Blind Phone (208) Main Street Fax (208) Gooding, ID pg. 1

2 Table of Contents Participant Information. 3 Education/Release of Information. 4 Authorization for Exchange of Confidential Student Information Form. 5 Questionnaire. 6 Employment History. 7-8 References. 9 Vehicle Registration Form 10 Disclosure Statement.. 11 ILS Wardrobe and Supplies pg. 2

3 PARTICIPANT INFORMATION PLEASE CIRCLE ONE THAT APPLIES STUDENT INFORMATION Are you: ASL User Hard of Hearing Oral with Sign Oral without Sign Student Name Last First Middle Address Street City State/Zip Home Telephone Number Work Telephone # Address Birthdate Age Gender County of Residence Emergency Contact Name Relationship Phone Number PLEASE PLACE AN X NEXT TO THE AREAS YOU NEED HELP WITH Balancing a checkbook Using public transportation BACKGROUND INFORMATION Budgeting money Buying a car Paying Bills (rent, heat, water, garbage) Taxes Applying for a job Organizational Skills Grocery Shopping Social Skills Cooking/preparing for meals Self-Advocacy Please Answer: Do you have your own bank account? Yes No Do you have a debit card? Yes No Have you used a debit card? Yes No Do you have a driver s license? Yes No Do you have a car? Yes No Do you plan to drive your car to ISDB? Yes No Are you certified in CPR/First Aid? Yes No Do you have a food handler s card? Yes No Do you have a Vocational Rehabilitation Counselor? Yes No If yes, name of your VR Counselor and telephone number: pg. 3

4 Education/Release of Information High School Attended Address Phone Number Case manager or Special Education Teacher/Director Required Documents High School Transcript GED Certificate Current Eligibility Report Current IEP Release of Information* Please complete and sign the *Authorization for Exchange of Confidential Student Information on the following page. This document must be returned with the above mentioned items to: Cristi Lancaster ILS Instructor Idaho School for the Deaf and the Blind 1450 Main Street Gooding, ID Fax: ((208) Office: (208) pg. 4

5 Authorization for Exchange of Confidential Student Information Student s Name: District ID: State ID: Grade: Sex: Native Language: Ethnicity: Birth Date: Age: District: School: Parent, Personal Representative, or Adult Student s Name: Address: Home Phone: City: State: Zip Code: Daytime Phone: A. The names of parties authorized to exchange information: I authorize: Name Title Organization Address City State Zip Code (check either box or both, as needed) to release information to: to obtain information from: Name Organization Address City State Zip Code Title Official School Record Counseling Record Special Education Record Chemical Abuse/Dependency Report Teacher, Counselor, Staff Observations Other (specify) Health Record Psychological Records Medical Report Transcripts Social Work Report B. The information to be released: C. The Purpose of this request: This authorization takes effect the day you sign it, and: Expires after the requested information is received. Continues until (a date not more than 12 months after signature date). D. Effective Date of Authorization: By signing authorization, I understand that the parties named above are permitted to exchange written and verbal information regarding my child. The parties may also accept a photocopy of this release form and give it the same full force and effect as the original. I further understand that I may revoke this authorization in writing at any time by providing a copy of my revocation to the parties named above. The information used or disclosed under this release might be disclosed by the school district as an educational record, pursuant to FERPA, and might no longer be protected by HIPAA. Parent, Personal Representative*, or adult student signature Date *If signed by a Personal Representative, please set forth the Personal Representative s authority to act for Student: It is intended that this Authorization meets the requirements under the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). AUTHORIZATION FOR EXCHANGE OF CONFIDENTIAL STUDENT INFORMATION 2006 Eberhater-Maki &Tappen, PA (This form may be copied for educational use by Idaho school districts.) pg. 5

6 QUESTIONNAIRE 1. Why do you want to join the Independent Living Skills Program? PLEASE ANWER THE FOLLOWING QUESTINOS 2. What are two goals you have for work? (A) (B) 3. What is your goal for future living arrangements? pg. 6

7 EMPLOYMENT HISTORY 1. Present or Last Employer Employer s Address Employer s Phone Number Your Title Months & Years in this Position From / to / Total Months Employed Average Hours/Week Immediate Supervisor s Name Reason For Leaving Volunteer Position Yes No Were you involved in a school Work Program? Yes No Did you have a Job Coach? Yes No EMPLOYMENT HISTORY Specific Duties: Certificates Received 2. Present or Last Employer Employer s Address Employer s Phone Number Your Title Months & Years in this Position From / to / Total Months Employed Average Hours/Week Immediate Supervisor s Name Reason For Leaving Volunteer Position Yes No Were you involved in a school Work Program? Yes No Did you have a Job Coach? Yes No Specific Duties: Certificates Received pg. 7

8 EMPLOYMENT HISTORY (CONTINUED) 3. Present or Last Employer Employer s Address Employer s Phone Number Your Title Months & Years in this Position From / to / Total Months Employed Average Hours/Week Immediate Supervisor s Name Reason For Leaving Volunteer Position Yes No Were you involved in a school Work Program? Yes No EMPLOYMENT HISTORY (CONTINUED) Did you have a Job Coach? Yes No Specific Duties: Certificates Received: List any other non-paid work experience or volunteer positions: Please List the types of jobs you are interested in: Do you have a resume? YES NO What work skills do you have? pg. 8

9 REFERENCES List three references that are not relatives or close friends. Teachers, employers, supervisors and/or group leaders over the age of 18 are required. Be sure to inform your references that they may be receiving a call. Reference One Name Last First Relationship Address Street City State/ZIP Home Phone Number Work Phone Number Cellular Phone Number Address EMPLOYMENT HISTORY Reference Two Name Last First Relationship Address Street City State/ZIP Home Phone Number Work Phone Number Cellular Phone Number Address Reference Three Name Last First Relationship Address Street City State/ZIP Home Phone Number Work Phone Number Cellular Phone Number Address pg. 9

10 VEHICLE REGISTRATION FORM Name as it appears on your driver s license; PRIMARY VEHICLE Last First Middle Make Model Color Year License Plate Number Insurance Company Agent name/phone Number Name as it appears on your driver s license; ALTERNATIVE VEHICLE #1 Last First Middle Make Model Color Year License Plate Number Insurance Company Agent name/phone Number Name as it appears on your driver s license; ALTERNATIVE VEHICLE #2 Last First Middle Make Model Color Year License Plate Number Insurance Company Agent name/phone Number Attach a copy of the following for our records Automobile Insurance Card Driver s License pg. 10

11 DISCLOSURE STATEMENT This disclosure statement shall be completed and signed prior to acceptance into the Independent Living Skills Program at the Idaho School for the Deaf and the Blind. (Please note: answering yes to anything below does not necessarily prevent you from being accepted into the ILS program.) 1. Have you ever been charged for a violent offense? Yes No If yes, what for? when? By which police department? 2. Have you been charged/arrested/adjudicated for any sexual offense? Yes No If yes, what for? when? 3. Are you a registered sex offender? Yes No If yes, what state? what county? 4. Have you ever been suspended from school? Yes No If yes, why? when? Where (school name)? 5. Have you ever been expelled from school? Yes No If yes, why? when? Where (school name)? 6. Have you in the past or are you currently receiving Mental Health Services? Yes No If yes, what for? Name of agency/clinic? 7. Have you ever tried to harm yourself? Yes No If yes, when? What was the outcome? 8. Do you have a history of drug or alcohol abuse? Yes No If yes, what kind? How often? pg. 11

12 Items to Bring Wardrobe / ILS Supplies ILS Class Clothing No Shorts, dresses, skirts, or flip flops are allowed as you may be called in to work with little or no notice Acceptable tops include: T-shirt, blouses and shirts meeting the following criteria: shirts may drop no lower than approximately three inches below the neckline so as to maintain modesty no tank tops or spaghetti strap tops, unless layered with an acceptable shirt no cut-off shirts or tops that expose the navel all shirts should be long enough to cover skin when sitting, standing, or bending over fishnet or see-through tops will be acceptable only when worn with another top. Clothes/jewelry with inappropriate sexual logos, symbols, markings, words/language, pictures, alcohol, drug, or tobacco ads will not be allowed. Pants should rest comfortably on the hips, no sagging of pants is allowed. Headwear may be required at some job sites however, hats, caps, beanies, hoods, bandanas will not be allowed to be worn in the school building during school hours (from the moment you enter the school in the morning to the last bell of the day). This includes the cafeteria, classrooms, gym, tarpit, and/or hallways. Hoodies may be worn with the hood down. Pajamas (pjs), sleepwear, slippers, etc. are not allowed Shoes are to be worn at all times in classes. Make sure you wear your tennis shoes every day in the event you are called in to work. Sunglasses are not to be worn in the building or on your job site unless you have an eye condition that requires you wear them. Work Clothing 3-4 pairs of appropriate jeans (without rips, shreds) jeans must fit to your body type 1 pair of closed toed shoes comfortable for working long hours 3-4 appropriate one colored T-Shirts (no prints) No Shorts or flip-flops are allowed at work at any time 2 pairs of tennis shoes tennis shoes are the only footwear to be worn on the jobsite unless your supervisor directs you otherwise Work clothing will vary depending on your job placement employers and ILS instructor can alter what you need to bring every week. Some employers will issue you a uniform you are responsible for keeping your uniform clean and ready for work. ILS Program Items $30.00 Class Fee 1 Package of Thank You cards 1 Water Bottle 1 Small Notebook 1 Watch or Cell Phone to track time at work 2 Boxes of large band aids if you have tattoos that are otherwise not covered by your clothing all tattoos must be covered in the classroom and on the job site Optional Lunch Bag pg. 12