Career Academy Applications - Gulfstream Goodwill

"*" indicates required fields

Student Information

Student Name*

First Last

Current / Most Recent School Attended*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Date of Birth*

Gender at Birth*

Parent Information

Student Name*

First Last

Parent Name*

First Last

Parent Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent Phone

Student Information

Student's Legal Rights*

Student makes his/her own legal decisions

Parent has guardianship (Court documentation must be provided.)

Parent is Guardian Advocate

Education Information*

Student has graduated with a special diploma

Student is currently on a special diploma track

Student earned a standard diploma via ACCESS Points and has deferred receipt of diploma

Student is on a standard diploma via ACCESS Points

Other

Transportation: How do you plan to get to the Project SEARCH work sites?*

City bus

Palm Tran Connection (door-to-door service)

Parent (or family member)

Drive self

In a few words, how do you think you learn best? (For example: Small groups, hands-on experience, extra time)*

Service Agencies

Are you a client of Vocational Rehabilitation?*

Yes

Receiving services

In process of application

Have not applied

If yes, what is your Vocational Rehabilitation counselor's name?

Are you on the Med-Waiver?*

If yes on the Med-Waiver, what is your support coordinator's name?

If no on the Med-Waiver, are you on the Med-Waiver waiting list?

Independent Living

List any health or medical issues that may impact a successful job placement.

Medications, dosages and time of day taken by student:

Who do you live with?

Behavioral Summary

In the last year, have you had any discipline referrals?*

If yes, please explain:

In the last year, have you been suspended or sent home from school or work for behavioral reasons?*

If yes, please explain:

TRANSITION SERVICE NEEDS - check ALL areas you need help with

Daily Living Skills

Budgeting and finances

Cooking

Meal planning

Home maintenance

Taking care of my health

Advocating for myself

Personal safety

Academics

Computer skills

Money skills (sales advertisements, banking)

Reading (current events)

Employment

Identifying my career interests

Completing job applications

Job coaching

Travel Training

How to call a cab

How to use public transportation

Obtaining a driver's license

Community Experience

Recreation and leisure activities

Shopping skills

Social activities

Work Experience Information

Employer 1

Start Date

End Date

Job Title

Job Duties

Supervisor's Name

Supervisor's Phone

Compensation

Employer 2

Start Date

End Date

Job Title

Job Duties

Superviser's Name

Superviser's Phone

Supervisor's Phone

Employer 3

Start Date

End Date

Job Title

Job Duties

Supervisor's Name

Supervisor's Phone

Compensation

IMPORTANT INFORMATION - In this section mark all the things you can do on your own

Are you married?*

Do you have children?*

Independent Living*

Cooking

Laundry

Driving

Getting up on your own

Planning for your future

Living on your own

Employment*

Arriving on time

Following uniform requirements

Following written directions

Following verbal directions

Telling time (start time, break time, etc.)

Cashiering/money skills

Customer service skills

Social / Recreational Leisure*

Spend time with friends

Volunteer

Have a hobby you enjoy

Involved in sports

Handle frustration well

Handle conflict well

Follow directions well

Team player

Academics*

Reading

Math

Attending school regularly

Keeping track of your money

Speaking in front of others

Computer skills

Working independently

Working with others

Personal*

Reliable

Responsible

On time

Get along with peers

Get along well with those in authority

Respectful of others

Is there anything else you would like us to know about you?

Student Response Questions

Please answer the following questions to the best of your ability. Answers should be brief. Information you provide may be used during the interview.

What activities do you do for fun?*

Do you have any special hobbies or projects that you like to do at home?*

What makes you frustrated?*

What calms you down when you feel anxious, nervous or angry?*

Do you spend time with friends outside of school?*

Why would you like to participate in the Project SEARCH / Project Employment Program?*

List Three References (No Family Members)

Note: During the interview, be prepared to discuss job skills you would like to learn, things you need to learn to be more independent, work experience and career goals. Please bring your social security card and government-issued photo identification. Acceptance into the program cannot be approved without these documents.

List Three References (No Family Members)

Please provide 1 work, 1 school and 1 personal reference

Work Reference Name*

First Last

Work Reference Phone*

Work Reference Email

What was the person's role in relationship to you?*

School Reference Name*

First Last

School Reference Phone*

School Reference Email

What was the person's role in relationship to you?*

Personal Reference Name*

First Last

Personal Reference Phone*

Personal Reference Email

What was the person's role in relationship to you?*

This application was completed by (if other than applicant):

Phone

Relationship to Applicant

Name

First Last

Phone

This field is for validation purposes and should be left unchanged.