Website-project-case-application-11-16-15

Dear Applicant: Thank you for your interest in Project CASE In order to ensure that your application is complete, please make certain that you have completed the following: Name of Applicant _Date Apply to South Plains College or Texas Tech University Register with the Student Disability Services Office on the campus you plan to attend Meet with a counselor from the Student Disability Services Office to make sure your paperwork is in order and you can be issued a Letter of Accommodations Attach the following to your Project CASE application:  A copy of your college acceptance letter  A copy of your most recent psychological evaluation (within the past years) showing diagnosis and subtest scores from each assessment  If you have had previous college experience, an unofficial transcript from that institution  Letter of Accommodations, as available from your campus Student Disability Services Office  Two Recommendation Forms from former teachers, employers, or other significant individuals (other than relatives) who have known you for at least one year Your application will not be processed until a completed application; including both Recommendation Forms, are received by the Project CASE office Completed applications will be reviewed by Project CASE faculty and staff Students will be contacted for a personal interview once these documents have been reviewed Student applications should be submitted by August st for fall semester and December 1st for spring semester Students planning to attend summer sessions should submit their applications for Project CASE by May st _4 Submit your completed Project CASE application with attached documents to: Dr DeAnn Lechtenberger, Director for Project CASE Burkhart Center at Texas Tech University Box 41071 2902 18th Street Lubbock, Texas 79409-1071 deann.lechtenberger@ttu.edu 806-834-7804 Page Updated 4-24-15 BC-CASE–02 Project CASE: Connections for Academic Success and Employment GENERAL INFORMATION Project CASE is a program designed to provide support for students with developmental disabilities, including autism spectrum disorders (ASD) in their pursuit of academic achievement that will lead to a student’s personal employment and career goals Students are expected to meet the same expectations and criteria of any other qualified student attending Texas Tech University or South Plains College This means you as a student must complete all required coursework and meet the technical requirements of your selected program Coursework, curriculum, and/or educational programs cannot be altered or modified in any way Due to the nature of the work involved in a selected career, certain conditions may prohibit an individual from safely and accurately performing the tasks required to be employed Such conditions may preclude admission to specific programs If you are unsure whether or not you can meet the program requirements due to your disability, please contact the specific program you are interested in at Texas Tech University or South Plains College You may also contact your campus Student Disability Services Office By signing below, I acknowledge that I am able and willing to work to meet all technical and academic requirements of the program of study that I have selected If accepted into Project CASE, I agree to actively pursue and complete an academic degree or certification at Texas Tech University or South Plains College I also agree to participate in all Project CASE meetings and business internships as long as they not interfere with my scheduled classes I also acknowledge that I agree to allow information about my academic and vocational outcomes while in the program to be used as part of a research study documenting the effects of Project CASE I understand that admission and/or enrollment into either Texas Tech University or South Plains College does not automatically grant admission into Project CASE or the program of study I have chosen I understand that the Project CASE program and research study will only accept a limited number of students each year on each campus In order to complete my application for Project CASE, I understand that my application will be reviewed and I will be contacted to set up a personal interview with the Project CASE faculty and staff Student Signature _ Date Date Application Received: NAME OF APPLICANT: Last Name First Name Middle Initial COLLEGE ELIGIBILITY Yes, please provide proof of acceptance to: _Texas Tech University South Plains College Are you registered with your campus Student Disability Services? YES NO Name of your contact at Student Disability Services: (Texas Tech applicants only) Are you registered with the TECHniques Center? _ Name of your contact at the TECHniques Center: Are you currently receiving services through the Department of Assistive & Rehabilitative Services (DARS)? _YES _NO Name of your DARS contact _ Phone number for DARS contact If you are not currently receiving services through the Department of Assistive and Rehabilitative Services (DARS), are you willing to apply within the first semester with Project CASE if you need job coaching or other Vocational Rehabilitation services from DARS? _YES NO (initial here that you understand the following statement) One of the major goals of Project CASE is to assist students in their career pursuits through their successful completion of a technical certification or academic degree that will prepare them for work in their chosen field; however, Project CASE cannot guarantee any student a specific job once they complete their program of study BIOGRAPHICAL INFORMATION ***For students attending college and away from home for the first time, we strongly recommend students live on campus CURRENT ADDRESS: Street Address: _ City: _ State: _ Zip: PHONE NUMBER: [Home] ( ) [Cell phone] ( ) EMAIL: DATE OF BIRTH: AGE GENDER: PRIMARY LANGUAGE: English Spanish Male Female Other, specify: _ FATHER’S NAME: _MOTHER’S NAME: Father’s email: Mother’s email: Phone: [Home] ( ) [Mobile] ( ) _ Family Address, if different than yours: (skip this if it’s the same address as above) Street Address: City: State: _ Zip: _ PERSONAL STATEMENTS What are your goals and interests in finding a job after college? _ _ _ _ _ _ Have you decided on a major course of study? YES NO If yes, what is it? _ BACKGROUND Are you a United States citizen? _YES _NO ETHNICITY: _ Do you have dependents under the age of 18 currently living with you? If so, how many? If so, you have reliable child care in order to attend classes? YES _NO Do you need assistance with child care to insure your regular attendance in class? YES _NO MEDICAL/HEALTH HISTORY What is your documented disability? _ (You will be required to provide a current psychological assessment that is no more than years old in order to document your disability) Do you currently take medications? Yes No If so, what are the names of your medication(s)? _ _ Medical Conditions: (i.e., seizures, severe allergies) _ _ _ Adaptive Equipment: No Yes, please explain: _ _ EDUCATION/SERVICES/EMPLOYMENT EDUCATION (schools attended) Name of School City State Dates Attended From/To Highest Grade Completed CURRENT SERVICES (includes vocational, job training, in-home care, etc.) Case Manager or other Agency Contacts: Name of Contact Job Title Agency Sponsor Phone PREVIOUS SERVICES (includes vocational, job training, in-home care) Dates of Service From/To Type of Service(s) Agency that Provided the Service(s) City State EMPLOYMENT HISTORY Name of Employer Job Title Dates of Employment Wage Location TRANSPORTATION In order to participate in Project CASE, students must be able to have reliable transportation to and from the campus to attend classes and meet with the Project CASE staff Additional transportation may be required to and from internship sites or employment TRANSPORTATION (check all that apply) Family/Friends Provide Transportation Agency (group home) Provides Transportation Uses City Bus/Cab Independently Operates Own Vehicle (Car/Bike) Other, Name of Contact for Transportation (if other than yourself): LEGAL ISSUES Has the Applicant ever been Convicted (or adjudicated) of a public offense? If yes, please explain: No Yes Your application will not be considered complete until your completed application and required documents have been submitted to Project CASE in the Burkhart Center, Box 41071, Lubbock, Texas 79409-1071 Once you have submitted your application and documents, your application will be reviewed and you will be contacted by the Project CASE staff If you have further questions, please contact the Project CASE Director, DeAnn Lechtenberger deann.lechtenberger@ttu.edu I agree that the information provided is, to the best of my ability, accurate and complete Applicant Signature Date Guardian Signature (if appropriate) Date Recommendation Form (Make two copies of this form) Please provide a Recommendation Form to at least two individuals who know you well, but are not related to you Have them mail the completed forms to Project CASE as noted on the Recommendation Form Your application is not complete until both references are received To the applicant: Complete the information requested below and give this form to the person serving as a reference along with a stamped envelope addressed to Dr DeAnn Lechtenberger, Burkhart Center at Texas Tech University, Box 41071, Lubbock, TX 79409-1071 Applicant’s Name: _ Last First Middle I, the applicant, waive my rights to ever see this form and any supplementary notes or letters attached to this recommendation Student Applicant’s Signature Date Applicant: Do Not Write Below Line To the recommender: The person named above is applying for admission to Project CASE at Texas Tech University or South Plains College Project CASE is a specialized program designed to provide support for students with disabilities in their pursuit of a postsecondary degree or certification that will lead to a student’s personal career goals Thank you for your assistance How long have you known the applicant? How well you know the applicant? (Circle response that is most applicable): casually fairly well very well In what capacity have you known the applicant? _ _ _ Please rate the applicant on the characteristics shown below in comparison to students at the undergraduate level, and use the scale below where = weak, = fair, = good, = strong, and NA = not applicable or can’t judge Dependability Interpersonal skills Flexibility to handle change Ability to focus and meet deadlines Persistence to complete college degree/certificate Academic ability to be successful in college Problem solving skills Enjoys learning new things Expresses wanting to attend college Expresses the desire to be employed Independence 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 Please write a few sentences on your estimate of the applicant’s chances of successfully completing a postsecondary certificate or program of study Please share your opinion of the applicant’s likely performance in an employee, volunteer, or internship position Statements about the applicant’s emotional maturity and stability, character and integrity, and interpersonal skills will be helpful Recommender’s Name: _ Date: _ Position and/or Relationship to student: Address: Phone: _Email Thank you for your assistance Please return this form to: Dr DeAnn Lechtenberger Burkhart Center Texas Tech University Box 41071 Lubbock, TX 79409-1071 deann.lechtenberger@ttu.edu