RFL-Student Application Academy

Student Application
Ready For Life Academy
Postsecondary Transition Program
Hope College, Holland, MI
Ferris State University, Big Rapids, MI
Northern Michigan College, Traverse City, MI
Eligibility Requirements
Applicant Name*

First NameLast Name
Is at least 18 years of age and not older than 30 years of age.*

YesNo
Has an intellectual/developmental disability and/or autism.*

YesNo
Has health insurance (Medicaid, Medicare, Private).*

YesNo
Has exhibited an interest and desire for greater independence and parent(s)/guardian(s) support the pursuit of independence.*

YesNo
Has the capacity to independently navigate campus and to/from campus housing.*

YesNo
Possess or is willing to learn time management skills and can follow a schedule.*

YesNo
Can communicate with others effectively with/without accommodations.*

YesNo
Has a cell phone (prior to starting the program).*

YesNo
Has socially adaptive and responsible behavior so when left unsupervised is able to follow/adhere to rules and instructions.*

YesNo
Is willing to learn and use alternative forms of transportation.*

YesNo
Is independent in grooming and hygiene routines. ***

YesNo
Applicant is able to self-administer medicines. ***

YesNo
Is able to prepare simple meals (i.e., breakfast, sandwich, salad, use a microwave).*

YesNo
** Residential staff do not have the certification required to provide medication management or serve as a personal care assistant. If these services are required, the family will need to contract with a private provider for personal care and/or medical management during the program.

By signing this form, the potential participant and his or her parent(s)/Guardian(s) acknowledge having read and understood the basic eligibility requirements of the Academy and Residential Programs. All information provided must be accurate and complete to the best of your knowledge. Any intentional omission or misrepresentation of pertinent information may result in dismissal from the program.

This form must be signed and returned with the application packet. It must also be noted that this form includes ONLY the basic eligibility requirements. Final acceptance to the program will be determined by the Admissions Committee.
Participant Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Application
Please be prepared to provide the following with this application: 1) a recent photograph of the applicant, 2) $50 application fee, 3) high school transcript - can be unofficial, 4) most current IEP, 5) educational/psychological/behavioral evals/support services evaluations. Be sure to complete all sections of the application. Document submission and payment instructions are at the end of the application. Thank you for your thoroughness.
Student and Family Information (A)
(to be completed by the student and/or family member/guardian)
A. Student's Information
Student's Name*

First NameMiddle InitialLast NameNickname
Student's Address*

Street Address

Street Address Line 2

CityState

Zip CodeCounty
Home Phone*
Cell Phone*
Student Email*
example@example.com
Date of Birth*

MonthDayYear
Date
State ID Number*
Age*
T-shirt Size*
Enrollment Start Date*

MonthDayYear
Date
Campus - 1st Choice*
Campus - 2ⁿᵈ Choice*
Student receives support or services from: (please check all that apply)*

Supplemental Security IncomeVocational Rehabilitation ServicesSocial Security Disability InsuranceCommunity Living Support from local CMHMedical AssistanceOther
Type a question*

I am my own GuardianMy parents have Power of AttorneyMy parents are my GuardianWe have not filled out the paperworkOther
Student currently resides with:*

MotherFoster Parent(s)FatherBoth ParentsOther
B. Parent/Guardian Information
Parent/Guardian Information (Primary Contact)*

First NameLast Name
Home Phone*
Cell Phone*
Primary Contact Email*
example@example.com
Parent/Guardian Address (Primary Contact)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information (Secondary Contact)*

First NameLast Name
Home Phone*
Cell Phone*
Secondary Contact Email*
example@example.com
Parent/Guardian Address (Secondary Contact)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
C Siblings
Sibling #1

NameAge
Sibling #2

NameAge
Sibling #3

NameAge
Sibling #4

NameAge
Sibling #5

NameAge
Sibling #6

NameAge
D. Independent Activities
Have you ever been away from home before?*

YesNo
If "Yes," where did you go and how long were you away from home? Did you enjoy that experience?*
Educational Information (B)
(to be completed by parent or guardian)
Name(s) and location(s) of high school(s) attended*
Years attended*
Name(s) and location(s) of high school(s) attended*
Years attended*
Name(s) and location(s) of high school(s) attended*
Years attended*
Did you graduate from high school?*

YesNo
If yes, name of Certificate received*
Year graduated?*
Have you participated in general education classes in his or her high school years?*

YesNo
Please list the general education classes for their junior and senior years:*
What accommodations were used to support you in these classes?*
Identify learning strategies used to facilitate a positive experience.*
Name*
Relationship*
Email address*
example@example.com
Name*
Relationship*
Email address*
example@example.com
Work Information (D)
(to be completed by student with assistance from a parent or guardian)
Has the student demonstrated success in supported or independent work experiences (unpaid job tryouts or volunteer opportunities) in the community or the school?*

YesNo
If yes, please list work experiences and level of support required. (Student requires one-on-one supervision or periodic support to perform the job, or does she or he work independently?)*
If no, why has he/she not participated in school or community work experience?*
Has the student held a paid job in the community?*

YesNo
If yes, please list the jobs held, the dates of employment, the level of support, wages received, and the student's reason for leaving.*
Is the student currently employed in his or her neighborhood?*

YesNo
Does the student require specialized equipment, adaptations, or modifications, or specific reinforces at the workplace? If so, please describe:*
If the student has not been engaged in a paid employment position, why not?*
Behavior Information (E)
(to be completed by a parent or guardian)
Does the student demonstrate satisfactory school attendance?*

YesNo
How often is school missed for illness?*
How often is school missed for doctor appointments?*
Does the student demonstrate satisfactory home/school behavior?*

YesNo
If no, please describe the nature of the student's behavioral challenges:*
Does the client exhibit these behaviors:
Verbal aggression *

YesNo
Physical aggression to self*

YesNo
Physical aggression to others*

YesNo
Property destruction*

YesNo
Inappropriate sexual behaviors*

YesNo
Non-compliance*

YesNo
Elopement*

YesNo
Compulsive behaviors*

YesNo
Sudden Outbursts*

YesNo
Is there a current behavior plan in place*

YesNo
During class, the fire alarm goes off, and the building is being evacuated.*
An unknown adult asks the student to come with him or her.*
A college peer of the opposite gender initiates friendly conversation with this student.*
The student is in the dining hall or café for lunch unsupervised.*
The student has been given a schedule of times and places to be at for the day.*
Disability, Medical Conditions and Health Information (F)
(to be completed by a parent or guardian. please use space provided to answer the questions and elaborate as much as possible, and feel free to add extra pages if necessary).
Sex*

MaleFemaleOther
Height*
Weight*
Disability or Condition (Please check all that apply)*

Down SyndromeCerebral PalsyPrader/Willi SyndromeSpina BifidaAttention Deficit Hyperactivity DisorderAutismEmotional Disorder (Bipolar, Depression, etc.)Muscular Dystrophy
If chromosomal abnormality, please list diagnosis and explain.*
If intellectual disability, please list diagnosis and explain.*
If deaf/hearing impaired, please list diagnosis and explain.*
If student has a speech disorder, please list diagnosis and explain.*
If student is blind or visual impaired, please list diagnosis and explain.*
If student has an impairment not listed, please list diagnosis and explain.*
Please list all medications that you are currently taking. Include the dosage/frequency, purpose of the medications, and any side effect(s):*
Describe chronic health problems for which you see a doctor:*
List any food or drug allergies:*
Please describe the applicant's ability to communicate with staff and other students:*
Please list any significant medical and/or physical conditions that may impact your participation in social and/or recreational activities within the program; for example: severe allergies or visual disability:*
Do you have seizures?*

YesNo
Type*
Duration/Severity*
Frequency*
Are seizures controlled with medications?*

YesNo
Please list any assistive technology that you use (i.e., wheelchair, eyeglasses, prosthesis, walker, hearing aid, roll aid, etc.) and if you require accessibility accommodations.*
Do you currently receive private therapeutic services, such as physical therapy, occupational therapy, psychiatry, speech therapy, or behavioral therapy? If yes, please list.*

Immunization Requirements

We believe that the campus community is best served when every student is immunized. In compliance with recommendations from the American College Health Association, the following vaccines are required for all incoming Ready for Life Students:

MMR (Measles, Mumps, Rubella)	Tetanus, Diphtheria, Pertussis
Meningococcal Vaccine A, C, Y, W-135	Tetanus booster within the last 10 years
Serogroup B Meningococcal	Varicella Vaccine
Influenza	Meningitis B

Students must provide documented proof of these immunizations before entering the Ready for Life Academy program on the campuses of Hope College, Ferris State University and Northern Michigan College.

Application Checklist
Applicant Name*
Application will not be considered until ALL requested information is received. The application can be typed and/or printed neatly.

Application can be mailed to: Ready for Life, 3250 28th Street SE, Ste 102, Grand Rapids, MI 49512
You will recieve some follow-up communications where you will be asked to upload the following documents:

Current photoHigh School Academic Transcript - can be unofficial (including disciplinary records)Current or most recent IEP and any postsecondary program record(s)Educational/Psychological/Behavioral Evaluations/support services evaluation (OT, Speech, PT)
Application Checklist:

Completed application online (Sections A-F)Application fee of $50.00, payable as follows: Venmo to @ReadyforLife-Administration (please note applicant's name). Zelle - request QR code from info@rflnetwork.org. Check payable to Ready for Life, mailed to address above (note applicant's name on memo line).
Payment Submitted on (date)*
Via:*
This application was completed by*
with*

A lot of assistancea little assistanceno help (select one)

Academy Application and Acceptance Timeline

Applications are accepted throughout the year. Applications will be reviewed as they are received, with consideration for enrollment in the following fall semester. Admissions will be processed until all available slots are filled, at which point a waitlist will be established.

Important Dates:

• Student Interviews: ongoing

• Announcement Letters Sent: as accepted

• Acceptance Letter Return Due Date: within 2 weeks of receipt

• Tuition Assistance Application: May 1-30

• Tuition Assistance Letters Sent: June 15

□ Mandatory Student Orientation: summer prior to start of program

Should be Empty:

Student Application

Ready For Life AcademyPostsecondary Transition Program

Hope College, Holland, MIFerris State University, Big Rapids, MINorthern Michigan College, Traverse City, MI

Eligibility Requirements

Application

Student and Family Information (A)(to be completed by the student and/or family member/guardian)

A. Student's Information

B. Parent/Guardian Information

C Siblings

D. Independent Activities

Educational Information (B)(to be completed by parent or guardian)

Work Information (D)

Behavior Information (E)

Disability, Medical Conditions and Health Information (F)

Immunization Requirements

Application Checklist

Ready For Life Academy
Postsecondary Transition Program

Hope College, Holland, MI
Ferris State University, Big Rapids, MI
Northern Michigan College, Traverse City, MI

Student and Family Information (A)
(to be completed by the student and/or family member/guardian)

Educational Information (B)
(to be completed by parent or guardian)