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(605) 394-5120
730 E Watertown St, Rapid City, SD 57701
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Project Search Black Hills
Project Search Black Hills
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Project SEARCH Video
Entrance Criteria
Intern Handbook
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Home
About
Project SEARCH Video
Entrance Criteria
Intern Handbook
Partners
FAQ
Student Application
Counselor Form
Contact
Student Application 2023-24
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Applications must be received by Tuesday, February 28th, 2023.
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:
Committed to work competitively in the community at the conclusion of the Project SEARCH program.
Be at least 18 years of age.
Has met high school completion requirements.
Agree that this will be the last year of student services provided by their resident district.
Must be on an Individual Education Plan (IEP) with their resident school district.
Must be on an Individual Plan for Employment (IPE) with Vocational Rehabilitation.
Have independent personal hygiene and grooming skills.
Have independent daily living skills.
Demonstrate workplace behavior and social skills.
Take direction from supervisors.
Be able to communicate effectively.
Utilize transportation independently.
Utilize transportation independently.
Be able to pass a background check.
Have immunizations up to date.
Select All
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.
Select All
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.
Select All
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.
Select All
A. Student Information
Student Name
First
Last
Date of Birth
Month
Day
Year
Gender
Male
Female
Social Security Number
Street Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
No
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
Month
Day
Year
Parent/Guardian Consent
I agree to the release of records.
Today's Date
Month
Day
Year
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor's Name
First
Last
Job Title
Unpaid?
Yes
No
Dates of Employment Starting:
Month
Day
Year
Ending:
Month
Day
Year
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor's Name
First
Last
Job Title
Unpaid?
Yes
No
Dates of Employment Starting:
Month
Day
Year
Ending:
Month
Day
Year
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor's Name
First
Last
Job Title
Unpaid?
Yes
No
Dates of Employment Starting:
Month
Day
Year
Ending:
Month
Day
Year
Wage Starting:
Ending:
Job Duties:
Have you ever been fired or let go from a job?
Yes
No
If Yes, how many, and why:
Will you actively search for employment during and after the Project SEARCH year, until employment is obtained?
Briefly illustrate your plan to seek, locate, and maintain competitive employment, as well as the times and frequency you plan on committing; e.g., 1-5 hours a week.
I am willing to work:
Weekdays
Weekends
AM (Mornings)
PM (Afternoons)
Evenings
Overnights
Holidays
Overtime
Select All
Will you be seeking:
Full Time Employment, often 38-40 hours a week?
Part Time Employment, between 10-38 hours a week?
How many hours would be preferred?
How many are needed?
Where do you want to work, and why do you want to work there?
E. Independent Living
Have you identified reliable methods of transportation?
Yes
No
Please detail all methods:
How will you get to work if the above method becomes unavailable?
Taxi
Bus
Personal Vehicle
Carpool
Transportation provided by school
Other method of transportation:
Where do you plan on living?
Home
Relatives
Friends
Other:
F. Medications
Prescription Medications
1. Medicine Name
Time Taken:
Hours
:
Minutes
AM
PM
AM/PM
Dosage Amount:
Side Effects (such as drowsiness):
Prescribed for:
How long have you been taking this medication?
2. Medicine Name
Time Taken:
Hours
:
Minutes
AM
PM
AM/PM
Dosage Amount:
Side Effects (such as drowsiness):
Prescribed for:
How long have you been taking this medication?
3. Medicine Name
Time Taken:
Hours
:
Minutes
AM
PM
AM/PM
Dosage Amount:
Side Effects (such as drowsiness):
Prescribed for:
How long have you been taking this medication?
4. Medicine Name
Time Taken:
Hours
:
Minutes
AM
PM
AM/PM
Dosage Amount:
Side Effects (such as drowsiness):
Prescribed for:
How long have you been taking this medication?
5. Medicine Name
Time Taken:
Hours
:
Minutes
AM
PM
AM/PM
Dosage Amount:
Side Effects (such as drowsiness):
Prescribed for:
How long have you been taking this medication?
6. Medicine Name
Time Taken:
Hours
:
Minutes
AM
PM
AM/PM
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
No
Counselor's Name:
First
Last
Business Phone:
Are you receiving any of the following? Skip any non-applicable items.
SSDI:
Yes
No
SSI:
Yes
No
Unemployment:
Yes
No
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
No
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
No
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:
Month
Day
Year
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