PAY Check Basic Information (Pre-Application)

Thank for your interest in the Postsecondary Apprenticeship for Youth (PAY Check) program at the LSUHSC Human Development Center. Because PAY Check has a high volume of interested persons, we have created a two-step application process. All submissions of this form are reviewed by the PAY Check Program Director. If it is determined you should move forward and apply, then you will receive notice from the Program Director with a link to the full application.

We ask and require information about the person completing the pre-application so that this person can receive a confirmation and, in the case of a third party, establish contact. We also want to establish contact with the applicant and the parent/guardian themselves. The person completing the application will possibly (but not necessarily) enter the same information in the role of either the applicant or the parent/guardian.

PAY Check is a collaboration between:

LSUHSC Human Development Center
Louisiana Rehabilitation Services (LRS)
School systems in your area
Employers in your area
Institutions of higher learning in your area

Parish	Institutions of higher learning	School Systems
Orleans	Delgado Community College Tulane University Loyola University New Orleans University of New Orleans	Orleans Parish Public Schools
Jefferson	Same as Orleans	Jefferson Parish Public Schools
St. Tammany	Northshore Community College	St. Tammany Parish Schools St. Paul's School

Name of Person Completing the Pre-Application *

First Name Last Name

E-mail of Person Completing the Pre-Application *

example@example.com

Phone Number of Person Completing the Pre-Application *

Please enter a valid phone number.

Relationship to PAY Check Applicant *

E.g., parent, guardian

Name of PAY Check Applicant *

First Name Middle Name Last Name Suffix

Applicant's Date of Birth *

Month Day Year

Applicant's E-mail *

example@example.com

Applicant's Phone Number *

Please enter a valid phone number.

Name of Parent or Guardian *

Prefix First Name Middle Name Last Name Suffix

E-mail of Parent or Guardian *

example@example.com

Parent or Guardian's Phone Number *

Please enter a valid phone number.

Name of School, School District, and/or Parish *

Expected Graduation Date of Applicant: Semester Season *

Expected Graduation Date of Applicant: Year *

Does the Applicant have an IEP or 504 plan? (Check all that apply) *

IEP 504 Plan Other (please explain)

By checking the following boxes, I understand the applicant will... (Check ALL boxes) *

Enroll in post-secondary education at Delgado Community College Complete two apprenticeships Complete Independent Living Skills training Complete Banking and Money Management training Complete Social Interactions training Complete Transportation Skills training Complete Self-Advocacy training

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