Job Foundation School to Work Application

Job Foundation School to Work Application
Date

MonthDayYear
Date
School District
Teachers Name
School Name
Last Year of Transition Services
County of Residency
Which Program are you applying for
Students Name (First, Middle Initial and Last Name)
Preferred Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Guardianship Status
If not own guardian please attach paperwork File Upload

Cancelof
PRIMARY CONTACT / GUARDIAN / SUPPORT PERSON: (Must include guardian if student is not own guardian)
Name

First NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
DEMOGRAPHIC INFORMATION
Date of Birth

MonthDayYear
Date
Gender
WhiteBlackAmerican Indian/Alaska NativeRace Not ListedHispanic/LatinoPrefer not to answer
Preferred Language
Interpreter Requested

Current Status of Services
Are you currently a client of DDA (Developmental Disabilities Services)
If no have you
If Yes Name of case manager
Are you currently a client of DVR (Department of Vocational Rehabilitation)
If No have you
If Yes Name of DVR Counselor (if known):
Are you receiving Social Security Benefits
Have you done benefits planning

STUDENT CERTIFICATION / AUTHORIZATION
- I promise the information in this application is true to the best of my knowledge. I know someone may check the information and may ask me for more documentation. I am also aware that if the information is not true, I can be terminated from the program if I am found ineligible. I allow this information to be used to see if I am eligible.
- I authorize the Department of Social and Health Services, Developmental Disabilities Administration (DSHS/DDA) to give information to the Walla Walla County Developmental Disabilities to see if I am eligible and to help me get services. All information will be kept confidential.
- I authorize Walla Walla County DD Program to contact me after this program ends to offer me other services and to ask about the long-term consequences of participation in the School-to-Work (S2W) Program.
STUDENT CERTIFICATION / AUTHORIZATION
GUARDIAN SIGNATURE IS REQUIRED BELOW
- I authorize the Walla Walla County DD Program to assist my student in obtaining employment.
- I authorize the exchange of information between the WWCO DD Program and any school, school district, or college in which my student is or has been enrolled. This exchange is authorized for any information relevant to the success of my student’s participation in the Job Foundations or School To Work Program and related activities. I understand that it may include standardized test results, transcripts, attendance records, performance reports and information from counselors, teachers, and other staff.
- I grant permission for my student to fully participate in educational, training, and employment related counseling activities provided by the Walla Walla County DD Program.
- I grant permission for my student to participate in and to go on any educational, work, and training related field trips or activities arranged by the Walla Walla County DD Program.
- I will provide any medical information that will assist the Walla Walla County DD Program in providing services to my student (include any physical, mental, or emotional challenges, allergies, as well as prescribed drugs your student is taking). I authorize the use of my student’s name and likeness in public displays or media releases to promote community awareness of our programs.
GUARDIAN SIGNATURE
Should be Empty: