Intern Application

Intern Application
East Bay Innovation's Project SEARCH programs are a one-year paid internship and job training program for adults with disabilities that are committed to seeking competitive employment in the community.

This employment and training program model features total immersion in a business setting in which interns complete up to three rotations (approximately 14-15 weeks each) in various departments within one of our three host business locations. It also includes classroom instructional time for professional skill building and career exploration opportunities — all while providing on-site skills training to support the goal of independence.

The primary goal of the program is to prepare each intern for competitive employment (a minimum of 14 hours per week) upon completion of the program.
Site Selection
Please select the Project SEARCH site at which you are applying:

Claremont Club and Spa (Berkeley) - Begins During JanuaryCounty of Alameda (Oakland)- Begins during FebruaryStoneridge Creek Senior Living Community (Pleasanton)- Begins during JanuaryUnsure-I would like to learn more about EBI Project SEARCH programs
Personal Data
Applicant Name*
Date of Birth*
Pronouns*

He/HimShe/HerThey/ThemOther
Date Applied*

MonthDayYear
Date
Applicant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone*
Please enter a valid phone number.
Home Phone
Email*
example@example.com
I currently reside with...*

SelfSpouseParent/ GuardianFamilyFriendOther
Conservatorship (if applicable)*
If applicable- you will be required to provide legal documentation of conservatorship if you are accepted into the program.
Conservator name
Conservator contact information
* please include address, phone number, email
Who referred you to EBI's Project SEARCH Program?*
*Referral source: RCEB Case Manager or other service provider
Referral Phone Number
Please enter a valid phone number.
Referral Email
example@example.com
Eligibility Criteria

All Project SEARCH applicants must meet the following criteria:
- Be at least 18 years of age with a diploma or 22 years of age having exited from the K-12 school system
- Be interested in future employment and possess necessary documentation in order to work
- Have an active case with the Regional Center of the East Bay
- Pass host business eligibility (Requirements may include proof of negative TB test, current immunizations including COVID-19 vaccinations, completion of host business paperwork, background clearance, and drug screening dependent upon the Project SEARCH site you are applying for)
- Be able to travel independently to and from the Project SEARCH site (with training)
- Ability to meet the host business' standards regarding professional communication and behavior in the workplace
- Adhere to host business' standards of dress, attendance, and other policies & procedures.
I confirm that I have read the Project SEARCH eligibility criteria
Benefit Information:
Which of the following benefit programs are you currently participating in? (select all that apply)*

SSI/SSDICalFreshHousing Assistance/Section 8NoneOther
Do you receive both SSI and SSDI?
Which of the following identification documents do you possess? (select all that apply)*

Driver LicenseSocial Security CardState ID Card
Are you currently a client of the Department of Rehabilitation (DOR)?*

YesNoUnsure
DOR Counselor Name and Phone
Are you currently a client of the Regional Center East Bay?*

YesNoPlan to ApplyUnknown
RCEB Case Manager Name and Phone
Are you currently working with an Adult Service Program or Supported Employment Agency?*

YesNoUnknown
Agency, Contact Name & Phone
Transportation
How will you get to Project SEARCH everyday?*

Own VehiclePublic TransportationWalkBikeRide Share (Lyft, Uber)Other
Are you interested in travel training?*
Project SEARCH participants must have the ability to travel independently to and from their host sites prior to the start date of each program. EBI can provide pre-internship travel training to support independence, safety awareness, and proficiency with utilizing public transit systems.
Do you have a Regional Transit Connection (RTC) Discount ID Card?*
The RTC Clipper card entitles qualified persons with disabilities to reduced fare on fixed route Bay Area transit systems.
Education and Training
Do you have a high school diploma or equivalent?*

High School DiplomaCertificateNone
If yes, name of high school
Other Education/Programs

TechnicalSome CollegeAssociatesBachelor’sMaster’sOther
Please list any other training programs or occupational licenses that you possess:
Employment Support & Future Job Preferences
What is your career of interest?*
How may your disability affect job performance?*
(i.e. behavior, sensory, communication, etc.)?
Adaptations/accommodations that you may need at work*
Please any medical conditions that you currently experience:*
(i.e. asthma, seizures, allergies)
Please describe your previous employment and/or volunteer experience:
What did you do? Which tasks did you like, which did you dislike?
How do you want to become employed upon the completion of Project SEARCH?*

Full-TimePart-TimeEither
Do you plan to work (at another job) while attending the Project SEARCH program?*

YesNo
Where will you work, and for how many hours each week?
Additional Questions
Why do you want to participate in the Project SEARCH Program?*
Do you have any commitments that would prevent you from participating fully in the M-F 9am-3pm Project SEARCH Internship Program (i.e., school, work, childcare, etc)?*
Have you looked into work training or supported employment programs other than Project SEARCH?
If so, please let us know which programs you have considered
References

Please list three references of a non-related individual (i.e. previous employer, school/program staff, neighbor, etc.)
Reference 1*

Reference Full Name

Relationship to Applicant

Phone numberEmail address

Additional contact info (optional)
Reference 2*

Reference Full Name

Relationship to Applicant

Phone numberEmail address

Additional contact info (optional)
Reference 3

Reference Full Name

Relationship to Applicant

Phone numberEmail address

Additional contact info (optional)
Compliance, Universal Release and Equal Opportunity
1.Acceptance into the East Bay Innovations Project SEARCH Program is dependent upon the Advisory Committee’s review. 2.Compliance: An applicant’s status within the program is contingent upon adherence to the policies and procedures of Project SEARCH. By signing, the applicant and/or guardian agree to comply. 3.Universal Release: The applicant’s records (RCEB, DOR, Academic) may be released for review by the Project SEARCH Program Staff and Advisory Committee. 4.Equal Opportunity: Project SEARCH placement will be made without regard to race, color, age, sex, national origin, cultural or economic background, housing circumstances, or presence of a disability.
Applicant’s Signature*

Clear
Date*

MonthDayYear
Date
Legal Guardian’s Signature (if applicable)

Clear
Date

MonthDayYear
Date
Did anyone help you complete this application?*

YesNo
Name & Contact information of the person that provided assistance:
Relationship to applicant:
PLEASE COMPLETE AND SIGN ALL THREE RELEASES BELOW

This consent shall remain valid for one year from the date signed
CONSENT TO RELEASE MEDICAL AND VOCATIONAL INFORMATION -RCEB

I give my consent for EAST BAY INNOVATIONS to request and receive records from the Regional Center of the East Bay in regards to my medical history, vocational history, educational history, and diagnosed mental and physical condition, including disabilities such as developmental, physical, drug, alcohol and psychiatric.

Information may be shared through written, verbal or electronic means.
Applicant’s Signature*

Clear
Date*

MonthDayYear
Date
CONSENT TO RELEASE MEDICAL AND VOCATIONAL INFORMATION -EDUCATION

I give my consent for EAST BAY INNOVATIONS to request and receive records and/or verbal information in regards to my vocational and educational history from my current or most recent teachers. (High School, Transition Program or College)

Information may be shared through written, verbal or electronic means.
Applicant’s Signature*

Clear
Date*

MonthDayYear
Date
CONSENT TO RELEASE MEDICAL AND VOCATIONAL INFORMATION -DOR

I give my consent for EAST BAY INNOVATIONS to share and collect information from the CA State Department of Rehabilitation in order to share information in regards to my medical history, vocational history, educational history, and diagnosed mental and physical condition, including disabilities such as developmental, physical, drug, alcohol and psychiatric.

Information may be shared through written, verbal or electronic means.
Applicant’s Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Intern Application

Site Selection

Personal Data

Eligibility Criteria

Benefit Information:

Transportation

Education and Training

Employment Support & Future Job Preferences

Additional Questions

References

Compliance, Universal Release and Equal Opportunity

PLEASE COMPLETE AND SIGN ALL THREE RELEASES BELOW