Email: AchieveSWMO@evangel.edu

Transitioning Youth with disabilities
to a life with purpose

Located at Evangel University
Education Department, Trask
Hall, Ste 201H
1111 N Glenstone Ave
Springfield, MO 65802

Achieve of Southwest Missouri
P. O. Box 8283
Springfield, MO 65801

Website: www.achieveswmo.com
Facebook: Achieve SWMO
Phone: 417-865-2815, ext. 8544

APPLICATION FOR ADMISSION

Thank you for your interest in the Achieve of Southwest Missouri Program on the campus of Evangel University.

Complete this application to the best of your ability. If needed, you may ask a parent or guardian for assistance.

You are encouraged to keep a copy of the completed application for your reference.

**Please fill out the application entirely. Every field and piece of information is extremely important so please fill it out to the best of your ability.

STUDENT INFORMATION

Name: Gender: Male Female

Mailing Address:

(if different)

Permanent Address:

Home Phone: Cell Phone:

Email: Date of Birth:

Have you applied for Vocational Rehabilitation services? No Yes

Are you receiving Vocational Rehabilitation services? No Yes, list the Vocational Rehabilitation Counselor’s name, email, and phone number:

Are you currently covered under a medical insurance plan? No Yes

How did you learn about Achieve of Southwest Missouri? School Teacher/Counselor/Principal Flyer Service Provider Conference/Fair Internet Search

Agency: Other:

FAMILY/GUARDIAN INFORMATION

Are you your own guardian? Yes No

If no, list the name of your legal guardian:

What is the name of the primary contact for communication with Achieve?

What is the preferred method of communication? Others: Email: Text:

Mother/Guardian:

Name:

(if different)

Mailing Address:

Work Phone: Home Phone: Cell Phone:

Employer/Occupation:

Email Address:

Father/Guardian:

Name:

(if different)

Mailing Address:

Work Phone: Home Phone: Cell Phone:

Employer/Occupation:

Email Address:

Why are you interested in the Achieve Program?

Do you have any questions or concerns about the Achieve program?

Describe how you have prepared for employment and other activities after high school.

What are your expectations for participating in Achieve (e.g., what do you see yourself doing while in Achieve and once completing Achieve).

Have you independently used public transportation to get to school or work? Yes No

Are you able to use a cell phone independently? Yes No Do not have a cell phone

A cell phone is required for participating in the Achieve Program. Are you willing/able to comply with this requirement? Yes No

Do you have a driver’s license? Yes No Do you have your own vehicle? Yes No

EDUCATION HISTORY OF STUDENT

(include K-12 and any post-secondary experiences)

NAME OF SCHOOL	LOCATION	YEARS ATTENDED	PUBLIC,PRIVATE, or SPECIALIZED	RECEIVED SPECIAL EDUCATION SERVICES?	COMPLETED Yes or No

When will/did you complete your high school education (month/year)?

What type of high school diploma will/did you earn?

Do/Did you have an IEP in high school? No Yes, submit a copy with the application materials.

Do/Did you have a 504 Plan in high school? No Yes, submit a copy with the application materials.

Do/Did you have a Behavior Plan in high school? No Yes, submit a copy with the application materials.

Identify the type of class setting/placement you participated in during the last two years of high school:
Inside a regular/general education class 100% of the time
Inside a regular/general education class at least 80% of the time
Inside regular/general education class 40% to 79% of the time
Inside a regular/general education class less than 40% of the time

Identify the type of class setting/placement you participated in during the last two years of high school: Complete independence Minimal Supervision Moderate Supervision Complete Supervision Other

Do/Did you receive services/supports outside the school setting?
No Yes, list what services and/or supports are/were received:

Indicate, in your opinion, how you feel you best learn new information: Auditory Visual Memorization Repetition Hands-on Experiential Learning Others

Describe any technology or assistive technology you currently use, or have used, to assist in living, learning, or working.

What, if any, accommodations were provided at volunteer or work activities? (e.g., job coach, visual cues)?

EXTRACURRICULAR/VOLUNTEER ACTIVITIES

ORGANIZATION	ACTIVITY DESCRIPTION	DATES	FREQUENCY

EMPLOYMENT HISTORY

EMPLOYER	POSITION and/or JOB RESPONSIBILITIES	DATES OF EMPLOYMENT HOURS/WEEK	REASON FOR LEAVING	PAID or VOLUNTEER	USED A JOB COACH YES/NO

To assist in the placement of a volunteer vocational opportunity, describe the circumstances regarding any difficult volunteer or work experiences you may have had. If none, indicate none.

MEDICAL/DISABILITY HISTORY

Name of Student’s Physician: Office Phone:

Address:

Date of last medical exam:

Do you require any assistance in self-care? No Yes explain:

If yes, does the student use any of the following mobility aids?

Prosthesis, specify: Braces Crutches Cane Manual Wheelchair

Motorized Wheelchair/Cart Other:

Do you require a service animal? No Yes, specify:

Have you ever had a seizure? No Yes, explain and provide dates and medical treatment:

Provide information on all medical conditions or diagnoses, other than common childhood illnesses.

MEDICAL CONDITION	DATE OF DIAGNOSIS	DESCRIPTION OF MEDICAL CONDITION	DAILY LIVING IMPACTED? Yes or No

Current Medications student is taking: No medications are required continuously

MEDICATION	AMOUNT and FREQUENCY	PURPOSE	PRESCRIBED or OVER THE COUNTER

Achieve does not provide assistance with dispensing medications, or perform services typically provided by a nurse or personal care attendant. As a student at Achieve, you will be required to be aware of and manage your own medication and/or personal care needs. Do you understand, and are able to perform, all medication and personal care needs? No Yes

Explain:

Provide information about any hospitalizations the student has had:

DATE OF HOSPITALIZATION	REASON FOR HOSPITALIZATION

Have you had any incidents of aggressive physical or verbal behavior requiring intervention? No Yes, list the date and nature of the situation(s):

Do you have a history of legal violations, arrest, or probation? No Yes, list the date and nature of the situation(s):

ADDITIONAL INFORMATION

Is there any additional information about yourself that you would like to share with the application committee?

REFERENCES

A minimum of three (3) references is required to be completed by non-relatives who have known you for at least six months.

One reference must be from an educator. Examples of other reference requests could be another educator, supervisor, minister, affiliated organization leader, employer, family friend, or a service provider.

Achieve will contact your references directly and provide them with the required forms. By providing the below requested information, you are indicating consent to contact your references and releasing them from any liability in the information they provide. List below, the requested information for your reference choices:

List references below:

If applicable, the following person assisted me in completing this application:

Name:

Relationship:

Phone Number:

Email:

My signature below indicates that all information contained in this application is factually correct and complete. I understand that the misrepresentation or omission of application information is sufficient grounds for canceling my admission or registration. I understand that I will not receive undergraduate credit for any classes or activities participated in while a student of Achieve of Southwest Missouri. I understand that during the application process, members of the application committee may contact my parents or the individual assisting me in completing this application.

Student Signature: Date: Printed Name:

My signature below indicates that all information contained in this application is factually correct and complete. I understand that the misrepresentation or omission of application information is sufficient grounds for canceling the student’s admission or registration. I understand the student will not receive undergraduate credit for any classes or activities participated in while a student of Achieve of Southwest Missouri.

Parent/Guardian Signature: Date: Printed Name:

Email: AchieveSWMO@evangel.edu

Transitioning Youth with disabilitiesto a life with purpose

APPLICATION FOR ADMISSION

STUDENT INFORMATION

FAMILY/GUARDIAN INFORMATION

Mother/Guardian:

Father/Guardian:

EDUCATION HISTORY OF STUDENT

EXTRACURRICULAR/VOLUNTEER ACTIVITIES

EMPLOYMENT HISTORY

MEDICAL/DISABILITY HISTORY

ADDITIONAL INFORMATION

REFERENCES

Transitioning Youth with disabilities
to a life with purpose