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ApplicantName District DateSubmitted
InterviewDate
CurrentTeacher
VocationalandIndependenceProgramVIP
HighSchoolTransitionProgramInternApplicationPacket
2018‐2019
VIPTimeline
Thursday,February1,20186:00‐7:30p.m.
OpenHouse(St.Luke’sBethlehem)—JointwithVIPProgram(SnowDate:February8,2018)
Wednesday,February28,2018TargetDatetoSubmitApplication
(Interviewguaranteedifsubmittedontime.Applicationswillstillbeacceptedafterthisdate.)
Thursday,April5,&Friday,April6,2018InternInterviewsandSelectionfor2018‐2019SchoolYear
June2018IEPMeetingsforthe2018‐2019SchoolYear
QuestionsorConcerns?CallMelissaJohnsonat(610)769‐4111ext.1058
Application Packet Page 2
ApplicationPurpose
ThepurposeofthisapplicationpacketistooutlinetheskillsetoftheVIPinterncandidate.ThisapplicationthenenablestheSelectionCommitteetoproperlyassesseachstudentcandidate’sskills,abilities,andbackground.Aparent,student,counselor,teacher,oremployermaybecontactedbytheSelectionCommitteetogatheradditionalinformation.Ourgoalistoselectstudentswhowilleventuallybeindependentandreachtheoutcomeofintegratedcompetitiveemployment.
ApplicationGuidelines:
1. AllstudentsaretocompletethispacketofinformationtobeconsideredforparticipationintheVIPHighSchoolTransitionProgram.Seechecklistbelow.
2. ReturncompletedpacketbyWednesday,February28,2018to:MelissaJohnson,SupervisorCarbonLehighIntermediateUnit#214210IndependenceDriveSchnecksville,PA18078Faxto:610‐769‐1098orScanto:[email protected]
Ifyouhaveanyquestionsorconcerns,pleasecontactMelissaJohnsonat610‐769‐4111,[email protected]
3. The*SelectionCommitteewillreviewtheapplicationand,scheduleinterviews.
4. NinestudentswillbeacceptedintoVIPeachyear.Aphonecallandanacceptanceletterwillbesenttothenewlyselectedinterns.Aletterwillbesenthomeinformingallotherapplicantsofthedecision.
5. Uponselection,theinternsandparent(s)/guardian(s)willbeaskedtoattendanIntroductoryMeetinginJune.ThegoalsofthesemeetingsaretoanswerquestionsandensurealladditionalpaperworkiscompletedbeforeVIPbeginsinSeptember.
6. IndividualizedEducationPlan(IEP)willbedevelopedwiththeIEPteamforthe2018‐2019schoolyearbyJune2018.
* The VIP Selection Committee may include the CLIU Special Education staff and administrators, Office of Vocational Rehabilitation (OVR), and Lehigh Valley Center for Independent Living (LVCIL).
ApplicationChecklist CompletedApplication.
Photo.
CurrentIndividualEducationPlan(IEP)
CurrentReevaluationReport.*IncludeMostRecentMathandReadingScores/GradeLevelsandIQScores.
HighSchoolTranscriptwithAttendance.
SignattachedReleaseformsattheendoftheapplicationpacketforyourschooldistrict,OfficeofVocationalRehabilitation(OVR),andLehighValleyCenterforIndependentLiving(LVCIL).Thefollowinginformationistobecompletedbyapplicant,parents/guardians,and/orteacherscollaboratively:
Application Packet Page 3 PERSONALDATAApplicantName LastFirst Middle
Address Street City ZipCode
DistrictofResidence: SchoolCurrentlyAttending:
DateofBirth: Male Female
HomePhone CellPhone
E‐mailaddress SSN
ApplicantLivesWith Relationship
CellPhone E‐mailaddress
Parent/GuardianInformation
Parent/GuardianName: Parent/Guardiane‐mail:
Address: Street City ZipCode
Parent/GuardianHomePhone: CellPhone:
Parent/GuardianPlaceofEmployment:
Parent/GuardianWorkNumber: EmailAddress:
PreferredContactTimeandMethod:
Whatisyourprimarylanguage? English SignLanguage
Spanish Other
Application Packet Page 4 EMPLOYMENTBACKGROUND
Listjobsyoudoorhavedoneinschoolorinthecommunity(IncludeWork‐BasedLearningExperiences):
Employer JobTitle JobDutiesSupervisor
Name/ContactNumber
Paid Unpaid
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
Haveyoueverbeenfiredfromajob?Yes No IfYES,pleaseexplain:
Haveyoueverquitajob?Yes No IfYES,pleaseexplain:
Application Packet Page 5
Checklist
Intern: District: Age: DOB: Parent’sPhone(s): IEPExpirationDate: WorkBasedLearning: Yes NoLCTI/CCTI: Yes NoIfyes,whatprogram_________________________________________________________________________________________Areyouawareofwhatyourdisabilityis? Intern’sCellPhone(ThisisrequiredifyouareacceptedintoVIP)______________________________________________________________________
HaveyoucompletedpaperworkforOfficeofVocationalRehabilitation(OVR)?
(Thisisrequiredtobecompletedbeforeacceptance)
Yes No
OVRCounselorName: Number: Email:
HaveyoucompletedpaperworkforOfficeofIntellectualDisabilities(OID)?
Yes No
SupportsCoordinatorName: Number: Email:
AppliedforawaiverthroughOfficeofIntellectualDisabilities(OID)? Yes No
AppliedforanAutismWaiver? Yes No
Anyotherserviceproviderstobeapartofourteam?(mentalhealth,vision,etc.)
Yes No
Name: Number: Email:
Name: Number: Email:
CompletedapplicationsforTransportationLANtaVan/LANta(ThisisrequiredifyouareacceptedintoVIP) Yes No
Whatwastheresult?
PAStateID(ThisisrequiredifyouareacceptedintoVIP) Yes No
OriginalSSCard(ThisisrequiredifyouareacceptedintoVIP) Yes No
SocialSecurity#: ‐ ‐
PleasecheckallpossiblerotationsyoumaybeinterestedinexperiencingBedMaking FoodPreparation LinenAssistant TherapyandRecreationClerical HospitalityAide MailRoom ResidentTransportCustodial Housekeeping Maintenance Warehousing EnvironmentalServices Landscaping NursingAttendant FileClerk LaundryAssistant TherapyAide
Application Packet Page 6 INDEPENDENTLIVING
Pleaselistallmedicationstakenbythestudent,includingthedosageandtimeofday.
Medication(s) Dosage Timeofday Reason Howmayyourdisabilityaffectjobperformance(behavior,sensory,communication,academiclevel,etc.)?
Adaptations/accommodationsthatyoumayneedatwork? MedicalConcerns:
Application Packet Page 7 STUDENTRESPONSEQUESTIONWhydoyouwanttoparticipateintheVIPHighSchoolTransitionProgram?(Studentshouldcompleteinownwords)
Thisapplicationhasbeencompletedby:
Name Title Date
Signature
StudentSignature Date
ParentSignature Date
Application Packet Page 8
CONSENT FOR RELEASE OF INFORMATION
I hereby authorize (Name of facility, agency, or person) Lehigh Valley Center for Independent Living (LVCIL) to
release/obtain information to Carbon Lehigh Intermediate Unit #21 and (School District)_______________________________
from the records of (Student’s Name) _________________________, (Date of Birth) ____________, for the purpose of
(Reason) VIP Program.
The information to be released is:
Evaluation Report Treatment Plans Reevaluation Report Lab Reports Academic Evaluation Medical History Diagnostic Summary Medications Developmental History Psychiatric Evaluation Discharge/Aftercare Plan Psychological Evaluation Other information as deemed appropriate, please list: Exchange of Verbal Information
Individual Education Plan (IEP) High School Transcript with Attendance and Transition Formal and/or Informal Assessments
This consent will be in effect from __________________ until __________________ (Not to exceed 1 year). I have been informed that I may revoke this authorization at any time by written, dated communication to the respective unit, except to the extent that action has been taken in reliance thereon.
This form has been fully explained to me and I understand its content. ______________________________________________________ Signature of parent/guardian Date of signature ______________________________________________________ Signature of student Date of signature ______________________________________________________ Signature of witness Date of signature
Please forward information to the Attention of: Melissa Johnson
Name of facility, agency, or person: Carbon Lehigh Intermediate Unit #21
Address: 4210 Independence Drive, Schnecksville, PA 18078-2580
Phone: 610-769-4111, ext. 1219
Application Packet Page 9
CONSENT FOR RELEASE OF INFORMATION
I hereby authorize (Name of facility, agency, or person) Office of Vocational Rehabilitation (OVR) to release/obtain
information to Carbon Lehigh Intermediate Unit #21 and (School District)_______________________________ from the records
of (Student’s Name) __________________________________________, (Date of Birth) ____________, for the purpose
of (Reason) VIP Program.
The information to be released is:
Evaluation Report Treatment Plans Reevaluation Report Lab Reports Academic Evaluation Medical History Diagnostic Summary Medications Developmental History Psychiatric Evaluation Discharge/Aftercare Plan Psychological Evaluation Other information as deemed appropriate, please list: Exchange of Verbal Information
Individual Education Plan (IEP) To provide your contact information and to discuss vocational planning
This consent will be in effect from __________________ until __________________ (Not to exceed 1 year).
I have been informed that I may revoke this authorization at any time by written, dated communication to the respective unit, except to the extent that action has been taken in reliance thereon.
This form has been fully explained to me and I understand its content. ______________________________________________________ Signature of parent/guardian Date of signature ______________________________________________________ Signature of student Date of signature ______________________________________________________ Signature of witness Date of signature
Please forward information to the Attention of: Melissa Johnson
Name of facility, agency, or person: Carbon Lehigh Intermediate Unit #21
Address: 4210 Independence Drive, Schnecksville, PA 18078-2580
Phone: 610-769-4111, ext. 1219
Application Packet Page 10
CONSENT FOR RELEASE OF INFORMATION
I hereby authorize (Name of facility, agency, or person) _____________________________ to release/obtain information to
Carbon Lehigh Intermediate Unit #21 and (School District)____________________________________________ from the records of
(Student’s Name) _________________________, (Date of Birth) ____________, for the purpose of (Reason) VIP Program.
The information to be released is:
Evaluation Report Treatment Plans Reevaluation Report Lab Reports Academic Evaluation Medical History Diagnostic Summary Medications Developmental History Psychiatric Evaluation Discharge/Aftercare Plan Psychological Evaluation Other information as deemed appropriate, please list: Exchange of Verbal Information
Individual Education Plan (IEP) To provide your contact information and to discuss coordination of Services.
This consent will be in effect from __________________ until __________________ (Not to exceed 1 year).
I have been informed that I may revoke this authorization at any time by written, dated communication to the respective unit, except to the extent that action has been taken in reliance thereon.
This form has been fully explained to me and I understand its content. ______________________________________________________ Signature of parent/guardian Date of signature ______________________________________________________ Signature of student Date of signature ______________________________________________________ Signature of witness Date of signature
Please forward information to the Attention of: Melissa Johnson
Name of facility, agency, or person: Carbon Lehigh Intermediate Unit #21
Address: 4210 Independence Drive, Schnecksville, PA 18078-2580
Phone: 610-769-4111, ext. 1219
