GCESC Project LIFE Student/Parent Application Form

GCESC Project LIFE Student/Parent Application Form

Applications for the 25/26 School Year will be accepted from Dec. 1- Jan. 31. Interviews take place in Feb/ Mar. ***This form is for parents/guardians to fill out.***
Applicant's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Student Applicants Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parental Information
*Best email to for contact purposes
example@example.com
Name of Mother or Guardian

First NameLast Name
Mother's Phone Number

Area CodePhone Number
Name of Father or Guardian

First NameLast Name
Father's Phone Number

Area CodePhone Number
Academic Information
Grade or Year Level*
Date of 22nd Birthday*

MonthDayYear
Date
Name of Home School*
Current Teacher's Name*
Teacher's Phone Number

Area CodePhone Number
Teacher's Email
example@example.com
Will the student applicant have all credits necessary to meet graduation requirements at the end of this academic year?*

YesNo
Has the student applicant ever had behavior problems at school?*

YesNo
If answer is yes above, please explain.
Please list any medical or psychological conditions that affect the student applicant at school or work training sites.
Does the student applicant have any support services at school that are required by their current IEP?*

YesNo
If answer above is yes, please tell us which service(s).
Job Training Experience
Please have the student applicant check all that apply below regarding previous job training experiences.*

I have done job training or volunteered at my high school.I have done job training at my CTC or Career Center (including Career X)I have done job training with OOD and/or DD during the summer.I have had a paid job.I have volunteered in the community (not part of a school program).I have not participated in any job training programs.Other
Please provide details about job training experiences listed above.*
What are the student applicant's employment goals after graduation?*
Transition to Adult Services
Is the student applicant a DD (Developmental Disabilities) client?*

YesNo
If so, who is your DD Transition Coordinator or SSA?
Does the student applicant have a case open with OOD (Opportunities for Ohioans with Disabilities)?*

YesNo
If so, who is your OOD Case Manager?
Why is the student applicant interested in applying for Project LIFE? How will benefit it him or her?*
I AFFIRM THAT ALL STATEMENTS I HAVE INDICATED HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. ALSO, I AGREE TO THE RELEASE OF ALL PERTINANT SCHOOL (IEP & ETR) AND MEDICAL RECORDS TO PROJECT LIFE STAFF.
Applicant's Signature*

Clear
Name of Applicant*

First NameLast Name
Parent/ Guardian Signature*

Clear
Name of Parent/ Guardian signing the form*

First NameLast Name
Date Signed by Applicant & Parent/ Guardian*

MonthDayYear
Date
Should be Empty:

GCESC Project LIFE Student/Parent Application Form

Parental Information

Academic Information

Job Training Experience

Transition to Adult Services