VR Online Referral Form
STUDENT INFORMATION
Student's Name
*
First Name
Last Name
What school does the student attend?
*
What county does the student live in?
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Race
*
Ethnicity
*
Disability Documentation
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
PARENT/GUARDIAN INFORMATION
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
AGENCY MAKING REFERRAL
Institute for Music Business - Dr. Angela Moss Poole - Executive Director - drpoole@imbusiness.org - (678) 910-2487
ACCOMODATIONS FOR INITIAL MEETING WITH VR STAFF
Select all that apply
*
Do you require an American Sign Language interpreter?
Do you require an assistive listening device?
Do you require translated documents?
Do you require any other accommodation for your impairment?
TRANSITION YOUTH SERVICES REQUESTED
Select all that apply
*
Job Exploration Counseling (includes discussions on the student’s vocational interests, the labor market, and identification of career pathways)
Work Readiness Training (A 20 hour course that focuses on employability and work readiness skills)
Self‐Advocacy Training (A course that teaches students how to speak up for themselves and make decisions about their own lives)
Do you require any other accommodation for your impairment?
Postsecondary Educational Counseling (provides an awareness of post‐secondary career pathway options with job and career information) * Service in not currently available
Work‐Based Learning Experiences (includes hands on training for employability skills; may be paid or non‐paid)
STUDENT ACKNOWLEDGEMENT
I understand that through Vocational Rehabilitation, I will be offered limited Pre‐Employment Transition Services that can help me explore, prepare for, and make informed career‐based decisions. I understand that I must be an active participant in the services I choose to achieve my transition goals.
Signature of Student
*
Date of Signature
*
-
Month
-
Day
Year
Date
PERMISSION TO MAKE REFERRAL
By Signing this Pre‐ETS Referral, "I give Insitute for Music Business permission to submit this Pre-ETS Referral to VR. I understand I will be contacted by VR Staff to set up an initial meeting and acknowledge that my participation is required if my child is under 18 or if I am his/her Guardian.
Signature of Parent/Guardian/Age of Minority Student:
*
Date of Signature
*
-
Month
-
Day
Year
Date
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