PAYCheck Basic Information (Pre-Application)

Thank for your interest in the Postsecondary Apprenticeship for Youth (PAYCheck) program at the LSUHSC Human Development Center. Because PAYCheck has a high volume of interested persons, we have created a two-step application process. All submissions of this form are reviewed by the PAYCheck 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. Entrance into this program is through a waiting list. You can expect to receive communication within 30-60 days. If you have any questions, contact Tracy O'Donnell todon1@lsuhsc.edu.

PAY Check is a collaboration between:

LSUHNO Human Development Center
Louisiana Rehabilitation Services (LRS)
School systems in your area
Employers in your area
Delgado Community College

Name of PAYCheck Applicant*

First NameMiddle NameLast NameSuffix

Applicant's Date of Birth*

MonthDayYear

Applicant's E-mail*

example@example.com

Applicant's Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of School*

Expected Graduation Date of Applicant: Year*

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

IEP504 Plan

Name of Person Completing the Pre-Application*

First NameLast 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 PAYCheck Applicant*

E.g., parent, guardian

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

Enroll in post-secondary education at Delgado Community CollegeComplete two apprenticeshipsComplete Independent Living Skills trainingComplete Banking and Money Management trainingComplete Social Interactions trainingComplete Transportation Skills trainingComplete Self-Advocacy training

Anything else you want to share?