Second Chance Referral Form

Second Chance Referral Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Living Arrangements
Driver's License or State ID Number
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Race
Ethnicity
Highest Level of Education
Number of Years Attended
Graduated
Degree
Are you Bilingual?
Do you have transportation?
Do you have a disability?
Do you receive Disability Benefits?
Do you receive Vocational Rehabilitation Services?
Did you serve in the Armed Forces?
Do you carry an inhaler?
Do you have Diabetes?
Do you carry and Epi-Pen?
Do you have any allergies (including food)?
Comment/Note
REFERRAL SOURCE
Name of the person referring you
Agency or Organization (If Applicable)
Phone Number of Referring Person
Please enter a valid phone number.Format: (000) 000-0000.
Email of Referring Person
example@example.com
LEGAL HISTORY
Name of Case Manager or Probation Officer
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you have any traffic violations on record?
Comment/Note
Do you have any misdemeanors on record?
Do you have any felonies on record
Brief Summary of Criminal History
Upload Criminal Record

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Note: At this time Hope Services cannot accept individuals with any sexual offenses or a significant violent history into this program.
SECOND PART - VOCATIONAL GOALS AND EXPERIENCE
Select your program of interest - please select ONE
Culinary Arts Certification
• 20 Hours
• Includes classroom and hands-on training
• Must pass written and practical exams to earn certification

Construction Certification
• 80 Hours
• Includes classroom and hands-on training
• Must pass written and practical exams to earn certification
What type of work do you want to pursue after certification?
Any relevant work experience in the selected field? If yes, please describe.
RIGHTS & RESPONSIBILITIES: The following rights are guaranteed to you under Florida law. These will be fully explained to you at the time of and following admission to Hope Services. All individuals who apply for Employment Services are assured that their lawful rights shall be guaranteed and protected regardless of race, color, ethnicity, national origin, age, creed, sex, sexual orientation, financial status, military status, or disability. Individual Dignity: I have the right to be treated with dignity and respect, with access to all constitutionally protected civil rights. Federal law protects people with disabilities by the American Disabilities Act. Informed Choice: I have the right to request a change in the Employment Services provider by contacting my Vocational Rehabilitation Counselor. Confidentiality of Information and Records: Without my written consent, Hope Services will not reveal or distribute to any person or organization except for my Vocational Rehabilitation Counselor, any personal or professional information I provided to them. Medical Treatment: I have the right to emergency medical treatment if I should become ill or injured while in the presence of Hope Services personnel. I will be provided any medical treatment deemed medically and immediately necessary. I am aware that I am financially responsible for such medical, dental and/or transportation costs that result from such necessary treatment. Firearms & Weapons: I understand and agree that no firearms or weapons are to be in my possession while meeting with or engaging in employment activities with Hope Services personnel. Drug Abuse: I understand that if I test positive for illegal drugs or I am found with them in my possession while meeting with, or engaging in employment activities with Hope Services personnel, this will be reported to my Vocational Rehabilitation Counselor and Hope Services has the prerogative to terminate their services to me. Release of Responsibility: For me and my heirs and assigns, I hereby fully release Hope Services from all claims and actions, which I now have or may have after signing this release. I intend to release all claims for injuries, damages, or lost to my person or property, whether foreseen or unforeseen, which I may have against Hope Services while meeting with or engaging in employment activities with Hope Services personnel. I have freely and voluntarily signed this release and I have had the chance to have it explained to me.

Authorization
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Hope Services Incorporated, to release my relevant personal and professional information to my Vocational Rehabilitation Counselor and potential employers with the purpose of finding and maintaining employment. This release shall follow the policies of the Florida Department of Education, Division of Vocational Rehabilitation, and Florida Statute. My signature below indicates that I authorize the release of relevant medical records, including physical or mental disabilities, and drug testing, to my VR Counselor and/or potential employers for the purpose of assessing my employability. I understand and agree that they will be notified that I have given this specific written permission before the disclosure of these results.

Authorization - Please checkmark to accept Information release
PHOTO/VIDEO/RESUME RELEASE: I hereby authorize and give full consent to Hope Services Incorporated, to publish and copyright all photographs, videos and resumes in which my name, words or image may appear while enrolled in Employment Services of any kind with Hope Services. I further agree that Hope Services Incorporated may use these photographs, videos or resumes on their website, social media, advertisement brochures, newsletters, catalogs, posters, flyers, displays, slide shows, videotapes, CD-Rooms, and like publications, literature, or materials without limitations or reservations. Additionally, I understand and agree that use of photographs, videos or resumes does no constitute in any manner or waiver of Hope Services Incorporated policies, programs, or rules, nor does continued use constitute an agreement to continue my enrollment in Employment Services with Hope Services Incorporated. I hereby approve the foregoing and consent to the use of my name, words, or image subject to the terms mentioned above. I affirm that I have the legal right to issue such content.

Authorization - Please checkmark to accept photo/video/resume release
Client Acknowledgement
Client Signature
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Upload any documents

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Should be Empty:

Second Chance Referral Form

REFERRAL SOURCE

LEGAL HISTORY

Note: At this time Hope Services cannot accept individuals with any sexual offenses or a significant violent history into this program.

SECOND PART - VOCATIONAL GOALS AND EXPERIENCE