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The College Experience Student Application Form
Congratulations on your decision to apply to The College Experience! The College Experience a two-year residential, non-credit certificate program hosted by Russell Sage College in partnership with Living Resources. In this application, you will be asked to submit the following documents: IEP/504 plan, Psychological or psychoeducational evaluation. If you are applying under NYS Medicaid Waiver funding, you will also need to upload: SSI award letter, most recent Life Plan, Letter of Determination of Eligibility for OPWDD services, DDP2, and Notice of Decision (NOD) letter. Please collect them now to have ready. You will be able to save this application throughout the process and return at a later time. If at any point you have questions regarding the application, please reach out to our admissions counselor. Peter Russo: peterrusso@livingresources.org, or 518-218-0000 ext. 5513
Funding Source Applying Under
*
NYS OPWDD Medicaid Waiver
Private Pay
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Waiver Application Information
ONLY FILL OUT IF APPLYING UNDER THE NYS OPWDD MEDICAID WAIVER FUNDING. Please note, if you are accepted into the program your Self-Direction budget might need to be amended. Please reach out to us if you have any further questions.
Do you receive SSI/SSDI/SSP benefits?
Yes
No
Don't Know
Do you have an active Self Direction budget?
Yes
No
Don't Know
Medicaid Number
Are you OPWDD eligible or OPWDD enrolled (receiving waiver services)?
OPWDD Eligible
OPWDD Enrolled (Dayhab/Commhab)
Don't Know
TABS ID Number
Care Coordination Information
Do you have a Care Manager?
Yes
No
Don't Know
Care Manager Name
First Name
Last Name
Agency
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Please Upload the Applicants Life Plan
Browse Files
Drag and drop files here
Choose a file
If available, created by Care Manager
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Private Pay Information
If you are applying under the Private Pay funding and are NYS OPWDD waiver enrolled, you will have to disenroll from waiver services while remaining OPWDD eligible. Are you willing to disenroll from waiver services if accepted into the College Experience?
Yes
No
Need to think about it
Other
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Applicant Information
Name
*
First Name
Last Name
Personal Email
*
example@example.com
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Social Security Number
Optional
Form of Identification
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Choose a file
Examples: Copy of State Issued ID, Drivers License, Etc.
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Gender Identity
Please Select
Female
Male
Non-Binary
Gender Nonconforming
Prefer not to Answer
Other
Please Upload a Photo of the Applicant
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Drag and drop files here
Choose a file
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Have you previously applied to The College Experience?
Yes
No
If yes, year of previous application
Anticipated Start
e.g., Fall 2026
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Parent/Guardian Information
Parent/Guardian
*
First Name
Last Name
Parent/Guardian Type
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Additional Parent/Guardian
First Name
Last Name
Parent/Guardian Type
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
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Applicant Medical Information
Do you take any medication?
*
Yes
No
If you take medication, please list the medication name, dosage, and time of dispense.
Example Answer: Fluoxetine, 40mg, in the morning
Do you take the medications independently?
*
Yes
No
Mostly
Other
Please list all allergies/reactions (food, environmental, medications, etc.)
Please note if you require an EpiPen for any of these allergies.
Do you have a history of a seizure disorder?
*
Yes
No
Other
If yes, when was the date of your last seizure?
-
Month
-
Day
Year
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Do you take rescue medication for seizures?
If yes, list medication
Do you have any physical limitations?
Any medical needs that were not inquired about that would be important to share?
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Applicant Educational Information
Current School/Program
If attending anything currently
Previous School/Program
If different than current school/program
Dates Attended
Approximate
Name of High School
Graduation Year
Type of Diploma Received (or Expected to Receive)
(i.e. High School Diploma, IEP Diploma, Skills & Achievement Credential, etc.)
What is your favorite subject?
What subjects do you need extra help in?
What activities were you involved with in and out of school?
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Applicant Job/Volunteer Experience
You can skip this page if no job/volunteer experience
Job Title
Company
Paid or Volunteer?
Dates Worked
Approximate
Job Title
Company
Paid or Volunteer?
Dates Worked
Approximate
Additional Job/Volunteer Experience
Please list all others
Resume or CV
Browse Files
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Choose a file
Optional
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Applicant Personal Information
Disability Classification
*
What are your strengths?
What things do you struggle with?
What are some of your hobbies or personal interests?
Any history of, or current legal difficulties?
*
Yes
No
Have you ever been convicted of a misdemeanor or felony?
*
Yes
No
Any history of, or current substance abuse?
*
Yes
No
Any history of, or current difficulties with violence to self, others, or property?
*
Yes
No
Have you ever run away before?
Yes
No
Are you your own legal guardian?
Yes
No
Don't Know
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Disclosure
Please carefully read the information below. By signing my name below, I am acknowledging that I, the applicant, am submitting an application to The College Experience. I understand that admissions is competitive, and submitting an application does not guarantee acceptance. I understand that the rest of this application, including supporting documents, must be completed in order for my application to be considered complete.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Signature
*
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Parent/Guardian Assessment of Daily Living Skills Form
Please fill out this form to the best of your ability with information about the applicant.
Name of Parent/Guadian Completing Form
*
First Name
Last Name
Relationship to Applicant
*
How did you hear about the College Experience?
College or Transition Fair
Expo or Conference
High School Guidance Counselor
Care Coordinator
Educational Consultant
Friend/Family
CareerNext Website
Social Media
Newsletter
Other
If a friend or family referral, what is their relation to the College Experience?
Example: Former student or graduate, friend of CEP student, current student, etc.
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Residential Life Skills
Uses Stovetop
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Uses Oven
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Uses Microwave
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Uses Washer/Dryer
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Puts Away Clothes
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Cleans Bathroom
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Uses Dishwasher
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Safely Uses Knife
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
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Finance Skills
Can Make Purchase WIth Debit/Credit Card
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Can Check Online Bank Account
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Can Calculate Approximate Change
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Safely Carries Wallet
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Able to Follow Shopping List
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
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Personal Hygiene
Showers Regularly
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Brushes Teeth Daily
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Uses Deodorant
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Shaving
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Brushes Hair
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Chooses Clean Clothing
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
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Community Safety
Can Get Emergency Help
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Crosses Street at Crosswalk
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Uses Public Transportation
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Avoids Contact with Strangers in the Community
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
Navigates Community
*
Please Select
Independent
Minimal Assistance
Assistance Needed
Don't Know/ Unsure
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Short Answer
Please describe the applicant's challenges.
*
Please describe the applicant's strengths.
*
Describe the applicant's ability to interact with peers with disabilities and without disabilities.
*
Describe the applicant's ability to interact with adults, teachers, employers, etc.
*
Has the applicant ever been discharged from a school, program, or job?
*
Why do you think the applicant would be a good fit for The College Experience?
*
Has the applicant ever been hospitalized for psychiatric reasons?
*
If so, please date most recent hospitalization.
Does the applicant attend clinical therapy?
*
If so, how often?
Does the applicant have any environmental or social triggers we should be aware of?
*
Does the applicant present with any vocal or verbal stimming?
*
Please explain any special considerations that we should be aware of in regard to the applicant.
*
(i.e. personal habits, sensory issues, behavioral difficulties, suicidal thoughts, gestures, or attempts, medical conditions, anger management issues, use of illegal substances, and/or the potential for or history of self-harm, violence to others and/or property)
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Acknowledgment and Signature
By signing below, I am acknowledging that I have filled out this form as accurately as possible regarding information about the applicant. I understand that omission to information or false reporting could lead to dismissal after admission.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Signature
*
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Letters of Reccomendation
Please provide the contact information for TWO letters of support from non-family members. We will reach out to the contacts listed so please make sure to notify them to look out for an email.
Name
*
First Name
Last Name
Relation to Applicant
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Name
*
First Name
Last Name
Relation to Applicant
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Document Uploads
Please upload supporting documents.
IEP or 504 Plan
Browse Files
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Most Recent
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Psychological or Psychoeducational Evaluation
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Choose a file
Most Recent, preferred within 3 years
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SSI Award Letter
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Choose a file
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Letter of Determination of OPWDD Eligibility
Browse Files
Drag and drop files here
Choose a file
Cancel
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DDP2
Browse Files
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Choose a file
Created by Care Manager
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Notice of Decision (NOD)
Browse Files
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To show you are HCBS Waiver Enrolled (if applicable)
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Student Essay
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A brief statement written by the applicant on why they want to attend The College Experience.
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Submit
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