Student Application

Applications must be received by Friday, February 28th, 2022.

Nondiscrimination

It is the policy of Black Hills Special Services Cooperative (BHSSC) not to discriminate on the basis of any protected group status in its educational programs, activities, or employment policies and activities as required by following state and federal laws and regulation. Inquiries regarding non-discriminatory policies may be directed to the BHSSC Title IX Coordinator or to the South Dakota Regional US Office for Civil Rights listed below.

Gloria Pluimer, Title IX Coordinator

730 East Watertown Street Rapid City, SD 57701 605-394-5120

South Dakota Regional US Office for Civil Rights

999 18th Street Suite 417, Denver, CO 80202 Fax: 303-844-2025 TDD: 800-368-1019 Email: OCR.KanasasCity@ed.gov

I. Application Purpose & Guidelines

This application will help identify and outline the Project SEARCH student’s skills and abilities. This provides the information necessary for the Selection Committee to assess the candidate’s skills, abilities, and background. The Selection Committee may establish contact with the student, parents or legal guardians, past, present, or current employer, in addition to previous school faculty, e.g., principals, teachers, and counselors, to collect, confirm or validate additional information. Information will be used to identify and satisfy eligibility criteria for program acceptance. The goal is to identify students who will benefit from the Project SEARCH program, and to achieve competitive employment for 100% of the students.

Project SEARCH Selection Criteria

Please click "Select All" after reading the list of Selection Criteria:

The Selection Process includes the following:

Please click "Select All" after reading the Selection Process steps:

(1) All students are encouraged to attend a pre-application meeting. Students must visit the host business site to observe the culture, possible rotations, meet the instructor and job coaches before acceptance into the Project SEARCH Program;

(2) Late applicants must meet all entrance criteria and will be discussed by the selection committee on a case-by-case basis;

(3) Out-of-state applicants may be considered by the selection committee on a case-by-case basis, unless we are at capacity to serve students from South Dakota. The home state school district and home state VR (or an alternate source) will have to provide appropriate funding;

(4) Submit the online application form;

(5) The Selection Committee members will receive a copy of each application. Applications will be reviewed to determine if the student’s interests and skills align with the goals of the Project SEARCH Program;

(6) Once the application is received, an interview will be set up with the student and guardian (if applicable) and the Selection Committee, along with an informal skills assessment;

(7) If selected for participation in Project SEARCH, an IEP will be developed with the IEP team for the 2022-23 school year.

II. Project SEARCH Application Packet Checklist

The following items are required, and must accompany the applicant’s submission. Please click "Select All" after reading the list of required items upon application submission.

(1) The Completed Application;

(2) The Current Individual Education Plan (IEP), with Transition Goals;

(3) The Current (Most Recent Math and Reading Scores, Transition Assessment) Multidisciplinary Team Report and Determination of Special Education Services;

(4) The Applicant’s high school transcript or the records from the most recent high school;

(5) The most recent or last report card received.

Please *Upload* the required documents. If you are not able to do this, please *email* hhoeye@bhssc.org

Current IEP with Transition Goals

Max. file size: 16 MB.

Upload

Current Multidiscipinary Team Report

Max. file size: 16 MB.

Upload

Determination of Special Education Services

Max. file size: 16 MB.

Upload

High School Transcript / Records

Max. file size: 16 MB.

Upload

Most Recent Report Card

Max. file size: 16 MB.

The Following Items Must Be Provided Upon Acceptance

Please click "Select All" after reading the list of required items upon acceptance:

(1) Proof of Health Insurance (Social Security determination, if applicable);

(2) Copy of birth certificate;

(3) Copy of Social Security card;

(4) Current Immunization Records or Copy;

(5) Be advised that some locations may require a current drug screen and/or background check.

A. Student Information

Student Name

First Last

Date of Birth

Gender

Male

Female

Social Security Number

Street Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

B. Parent/Guardian Information

Parent/Guardian Name (living in applicant's household):

First Last

Address

Street Address Address Line 2 City State ZIP Code

Primary Email

Home Phone

Cell Phone

Workplace

Work Email

Work Phone

Parent/Guardian

First Last

Relationship to Student (i.e. Father, Mother, Grandparent, etc.)

Cell Phone

Address (if different from above)

Street Address Address Line 2 City State ZIP Code

Workplace

Work Email

Work Phone

Is the applicant his/her own legal guardian?

If guardianship has been established by a parent(s) or another party at age 18, then please answer no to this question.

Yes

If no, please provide the Legal Guardian’s name:

First Last

Note to Students and Parents/Guardians

Final placement into Project SEARCH will depend upon the Individual Education Plan (IEP) meeting and the Selection Committee. The student will seek competitive employment before the end of the 2022-23 school year.

RELEASE OF RECORDS:

The records for the student identified above may be transferred to Project SEARCH, their representatives, and to members of the Selection Committee, from his/her School of Residence to establish eligibility, and potential acceptance, pending review.

Student Consent

I agree to the release of records.

Today's Date

Parent/Guardian Consent

I agree to the release of records.

Today's Date

C. School Information

1. School District of Residence:

2. School/Program Currently Attending:

D. Employment Information, Work History, and Preferences

1. Employer

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Supervisor's Name

First Last

Job Title

Unpaid?

Yes

Dates of Employment Starting:

Ending:

Wage Starting:

Ending:

Job Duties:

If you do not have additional employment experience, please continue to the next page of the application.

2. Employer

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Supervisor's Name

First Last

Job Title

Unpaid?

Yes

Dates of Employment Starting:

Ending:

Wage Starting:

Ending:

Job Duties:

If you do not have additional employment experience, please continue to the next page of the application.

3. Employer

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Supervisor's Name

First Last

Job Title

Unpaid?

Yes

Dates of Employment Starting:

Ending:

Wage Starting:

Ending:

Job Duties:

Have you ever been fired or let go from a job?

Yes

If Yes, how many, and why:

F. Medications

Prescription Medications

1. Medicine Name

Time Taken:

Dosage Amount:

Side Effects (such as drowsiness):

Prescribed for:

How long have you been taking this medication?

2. Medicine Name

Time Taken:

Dosage Amount:

Side Effects (such as drowsiness):

Prescribed for:

How long have you been taking this medication?

3. Medicine Name

Time Taken:

Dosage Amount:

Side Effects (such as drowsiness):

Prescribed for:

How long have you been taking this medication?

4. Medicine Name

Time Taken:

Dosage Amount:

Side Effects (such as drowsiness):

Prescribed for:

How long have you been taking this medication?

5. Medicine Name

Time Taken:

Dosage Amount:

Side Effects (such as drowsiness):

Prescribed for:

How long have you been taking this medication?

6. Medicine Name

Time Taken:

Dosage Amount:

Side Effects (such as drowsiness):

Prescribed for:

How long have you been taking this medication?

Over-the-Counter Medications currently taking:

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

Please list any limitations that may impact an internship rotation or employment:

G. Service Agencies and Benefits

Do you have a Vocational Rehabilitation Counselor? (VR/DRS or SVBI)

Yes

Counselor's Name:

First Last

Business Phone:

Are you receiving any of the following? Skip any non-applicable items.

SSDI:

Yes

SSI:

Yes

Unemployment:

Yes

Please provide any other sources of unearned income:

What are your maximum earnings per month?

H. Behavioral Summary

Do you have any behaviors that might impact a successful job placement?

Yes

Please detail all behaviors and characteristics:

I. Severe Allergies

Do you have any severe allergies such as latex, bees, peanuts, gluten, or shellfish that we should be aware of?

Yes

If yes, please explain:

STUDENT RESPONSE QUESTION

Why do you want to come to Project SEARCH, what are your goals, and what outcome do you hope to achieve?

Provide three references (Not Family). Reference 1:

First Last

Reference 2:

First Last

Reference 3:

First Last

If you are accepted into the Project SEARCH program you must abide by the following terms and conditions and will be required to sign a Student Participation Contract:

I understand Project SEARCH is a one (1) school year training program and I will actively pursue competitive employment when I have completed the program. I understand that Project SEARCH is a School District program and will adhere to Resident District policies and procedures, unless otherwise specified. I understand that Rapid City Regional Health Project SEARCH follows the national Project SEARCH curriculum. I will complete my assigned job rotations within the host business. I will attend the program every day as scheduled. I understand that the Project SEARCH program correlates with the school calendar. I will dress appropriately and wear required attire. I will call my instructor when I am absent or tardy. I will learn to use public transportation when available. I will follow all the rules established by the program and host business. I will attend and be an active participant at our meetings with my rehabilitation counselor, parents, teachers, and business staff. I will obtain a state issued identification card and provide a copy on or before the first day of the program. I will provide a copy of my social security card and birth certificate on or before the first day of the program. At completion of the program, I will receive my high school diploma/certificate of completion and pursue competitive employment.

This application has been completed by:

First Last

Title:

Phone

Today's Date:

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