MRC Pre-Employment Transition Services Referral and Consent Form

MRC Pre-Employment Transition Services Referral and Consent Form
I. Demographics
Student Name: *
SSN (if required):
Primary Language: *
D.O.B.: *

Month Day Year
Date
Gender: *

Male Female Prefer not to answer
Race (mark all that apply):

American Indian or Alaska Native Asian Black or African American White
Ethnicity:

Hispanic or Latino Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race
Address: *
Phone: *
Email: *
example@example.com
Disability Documentation Type: *

IEP 504 Plan Medical Documentation Other
Disability Diagnosis:
Functional Limitations:
Medications:
Allergies:
II. Family/Emergency Contact
Name: *
Mailing Address:
Relationship:
Phone Number:
Email:
example@example.com
III. School Information
School Name: *
Grade: *
Expected Exit Date:

Month Day Year
Date
School Contact Name:
Contact Phone
Relationship:
Contact Email:
example@example.com
IV. Services Requested
*

Job Exploration Counseling Work Readiness Training Work-based Learning Experience Instruction in Self-Advocacy/Peer Mentoring Counseling for Enrollment in Post-secondary Education Program
V. Consent for Service
I am requesting Pre-Employment Transition Services based upon the criteria that I am a student with a disability. I understand I will need to meet with a Pre-ETS Provider and develop a service plan that will be approved by MRC before I start receiving services. I understand that, as a recipient of services from MRC, I have the right to seek advocacy services from the Client Assistance Program (CAP) at 1-800-478-1234 or http://www.dlc ma.org/.

For the specific purpose of participation in Pre-Employment Transition Services, I grant permission for the service provider to exchange information with the schools, authorized personnel, and MRC to verify services were provided to me.
Signature: *

Clear
Date: *

Month Day Year
Date
Parent/Guardian Name - Print:
** If student is under 18 or has a legal guardian, their signature is required **
Parent/Guardian Signature:

** If student is under 18 or has a legal guardian, their signature is required ** Clear
Date:

Month Day Year
Date
Should be Empty:

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MRC Pre-Employment Transition Services Referral and Consent Form

I. Demographics

II. Family/Emergency Contact

III. School Information

IV. Services Requested

V. Consent for Service