Hearts Career Camp Trainer

DEPARTMENT OF EDUCATION DIVISION OF VOCATIONAL REHABILITATION EMPLOYMENT SPECIALIST APPLICATION
FEDERAL TAX ID: PROVIDER CONTACT: SERVICES ES WILL PROVIDE:

NAME:Michael Hearts Academy, Inc 84-3303653

PROVIDER NUMBER: PHONE NUMBER: SUPPORTED EMPLOYMENT SERVICES
VR-5498
OJT
FIRST NAME
MAILING ADDRESS
MI
LAST NAME
MAILING
CITY
STATE
ZIP CODE
NAME OF SCHOOL
CITY, STATE
CREDIT HOURS EARNED QTRSEM
MAJOR/MINOR
Qualifications for Certification

Employees who will provide direct services must meet one of the following qualifications 1.Four years' experience or employment in a public vocational rehabilitation program; experience in job placement, job coaching, or counseling; or other related experience working with persons with disabilities. OR 2.A Master's Degree in a related field such as rehabilitation, counseling, social work, psychology, education, human resources, business administration, or economics, from an accredited college or university, and six month's experience as described above. OR 3.A Bachelor's Degree in a related field such as rehabilitation, counseling, social work, psychology, education, human resources, business administration, or economics, from an accredited college or university, and one year's experience as described above. OR 4.An Associate's Degree from an accredited college or university, or a Bachelor's or Master's Degree in an unrelated field, and two years' experience as described above.
All employees who will provide Supported Employment Services must also have a training certificate in Supported Employment from a state or nationally recognized Supported Employment Program. Please provide copy(ies) of the following, if applicable: Degree(s) Training Certificate(s)

Employment History must support the option chosen above. Reference checks may be conducted to verify this information. List those duties consistent with above qualifications under DESCRIPTION OF WORK PERFORMED. If more space is needed, please attach a resume.
EMPLOYER
ADDRESS
PHONE NUMBER
JOB TITLE
(MM/YYYY TO MM/YYYY):
DESCRIPTION OF WORK PERFORMED
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TO
YOUR NAME IF DIFFERENT FROM EMPLOYMENT
EMPLOYER
ADDRESS
PHONE NUMBER
JOB TITLE
(MM/YYYY TO MM/YYYY):
DESCRIPTION OF WORK PERFORMED
FROM
TO
YOUR NAME IF DIFFERENT FROM EMPLOYMENT
ADDRESS
EMPLOYER
PHONE NUMBER
JOB TITLE
MM/YYYY:
FROM
DESCRIPTION OF WORK PERFORMED
YOUR NAME IF DIFFERENT FROM EMPLOYMENT
ADDRESS
EMPLOYER
PHONE NUMBER
JOB TITLE
DATES EMPLOYED
(MM/YYYY TO MM/YYYY):
FROM
DESCRIPTION OF WORK PERFORMED
TO
PERFORMED:
YOUR NAME IF DIFFERENT FROM EMPLOYMENT
EMPLOYER
ADDRESS
PHONE NUMBER
(MM/YYYY TO MM/YYYY):
DESCRIPTION OF WORK PERFORMED
TO
DESCRIPTION OF WORK
PERFORMED:
YOUR NAME IF DIFFERENT FROM EMPLOYMENT
ADDRESS
EMPLOYER
PHONE NUMBER
JOB TITLE
(MM/YYYY TO MM/YYYY):
DESCRIPTION OF WORK PERFORMED
FROM
TO
DESCRIPTION OF WORK
YOUR NAME IF
YOUR NAME IF DIFFERENT FROM EMPLOYMENT
Volunteer Work Please enter any volunteer work you've performed in the areas of; job placement, job coaching, counseling or working with persons with disabilities. Include organization's name, and dates (mm/yyyy) of volunteer service.
Please enter any volunteer work youve performed in the areas of job placement job coaching counseling or working with persons with disabilities Include organizations name and dates mmyyyy of volunteer service
Will you be transporting VR clients?

If you will be transporting VR Customers, please provide the following:

Valid Automobile Insurance with minimum coverage 50,000/100,000 unless the Provider's Insurance

Coverage includes Automobile Liability which covers any Automobile. Please provide a copy of the Automobile Declaration page (not the whole policy
Revised June 2021
Certification I hereby certify that, to the best of my knowledge, the above information is correct. Omissions, falsifications, misstatements, or misrepresentations above may determine me unqualified to provide services to Customers of Vocational Rehabilitation under the above Provider's Manual. I consent to the release of my employment history from any of the above mentioned employers to Vocational Rehabilitation.
Signature

I hereby certify that I am a subcontractor or independent contractor of the above Provider and I have attached the employment agreement between myself and the Provider. Failure to provide this information will result in the Provider being in violation of the Employment Services Manual held with Vocational Rehabilitation.
Signature

Clear
I hereby certify that I am NOT a subcontractor or independent contractor of the above Provider.
Signature

Clear
I hereby certify that I've reviewed the Employment Specialist Training presentations on Services and Overview, and completed the VR New Employment Specialist Training Quiz. I've received a score of .This score will be independently verified by Vocational Rehabilitation.
Signature

Clear
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DEPARTMENT OF EDUCATION DIVISION OF VOCATIONAL REHABILITATION EMPLOYMENT SPECIALIST APPLICATION

VR-5498

OJT

MAILING

NAME OF SCHOOL

CITY, STATE

CREDIT HOURS EARNED QTRSEM

MAJOR/MINOR

(MM/YYYY TO MM/YYYY):

(MM/YYYY TO MM/YYYY):

MM/YYYY:

DATES EMPLOYED

(MM/YYYY TO MM/YYYY):

PERFORMED:

(MM/YYYY TO MM/YYYY):

DESCRIPTION OF WORK

PERFORMED:

(MM/YYYY TO MM/YYYY):

DESCRIPTION OF WORK

YOUR NAME IF