Project SEARCH Dane County 2016-2017 APPLICATION

Information

NAME: / DATE:
/ Project SEARCH Intern Profile / / APPLICATION STEPS
Enrolled in a Dane County School District. / February 20 - Application deadline
Complete and Submit Project SEARCH Application.
- School records: Current IEP, Behavior Support
Plan, Last Evaluation.
- Confirmation of DVR application.
- Confirmation of Dane County ADRC
application.
Able to actively engage in a 30 hour work weekwith good attendance.
Eligible for DVR services.
Eligible for long term adult support with Dane County (a limited # of applicants may be admitted who are not eligible for long-term support).
Wants to transition out of K-12 education following SEARCH internship. / February 27
Mandatory Skill Assessment Day. UW Hospital. Plan a full day. Completed independently by applicant.
Wants to work in a hospital or health care setting. / March – Gather additional information, schedule observations as needed.
Independently manages meals and all personal cares (with or without accommodations.) / March 31 - Acceptance/Regrets letters are sent out.
Independently meets hospital hygiene policies and infection control requirements. / / AFTER ACCEPTANCE and PRIOR TO SEPTEMBER 1
Has a history of interacting with people appropriately and respecting others' property. / April –IEP meeting to add summer services and change placement starting Sept 2016.
Takes direction from supervisors and modifies behavior as needed. / June - Attend Project SEARCH parent meeting before end of 15-16 school year.
Aged 18 to 21 and has completed 4 years of high school. / Summer - Participate in any necessary ESY services.
- Provide updated immunization records.
- TB tests are required prior to working at the
UW Hospital as part of the New Employee
Orientation Process.
Able to get to and from Project SEARCH daily (note: Special Education transportation does not operate to UW/VA Hospital site)
Can commit to year-long program to include summer 2017.

Submit Applications to: Marcia Ingvalson, Project SEARCH

Madison Metropolitan School District

Department of Student Services

545 W. Dayton St. Madison, WI 53703

or Email to:

Project SEARCH Application

Application should be completed by student with support from parents/guardians, and/or teachers only as needed. It is strongly encouraged that student will have attended the Project SEARCH Information Session, toured Project SEARCH and/or watched the Project SEARCH video prior to completing this application.

Name:
Address:
Phone Number:
Email address:
Birthdate:
Parent / Guardian:
Address:
Phone Number:
Email:
Preferred method of contact:
Parent / Guardian:
Address:
Phone Number:
Email:
Preferred method of contact:
Do you have a guardian? (circle one) Yes No In Process
If yes, Guardian name:
Address:
Phone Number:
Email:
Preferred method of contact:
Have you been approved for services with DVR? (circle one)
Yes No In Process
Name of DVR Case Manager or Contact Person:
Have you been approved for Dane County Adult Services? (circle one)
Yes No In Process
Name of Dane County Case Manager or Contact Person:

EDUCATION:

Will you have completed four years of high school by the end of this school year?
Yes No
Name of High School:
Name of Case Manager:
Case Manager Email:
What classes are you taking this year?

EXPERIENCE: (Include volunteer, non-paid training, paid employment)

Location / Length of Experience / Duties / Supervisor

PERSONAL STATEMENT:

In your own words, why do you want to be a Project Search intern?

(If this section is scribed, please write exactly the words used by the candidate.)

Signature______Date______

Thank you!! You will receive email confirmation when your application is received.

4