Welcome

Please note that when you are filling out this form whenever it asks for your signature you may use your finger, stylus, or mouse to sign your name, and you can use your smart phone, tablet or a computer to fill out this information.

After completion this form will be emailed to a secure location for our use.

Student Name (Last, First, Middle Initial)

School District Attended

School Building Attended

Home Address (Number, Street, Apt #, City, State, Zip Code)

Student Social Security Number

Student Ethnic Race Student Ethnic Race

Asian

Black or African American

American Indian

Alaskan Native

White

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

Grade attending this year

Date of birth

Name of Special Education Teacher, or School Counselor

Parent(s)/Guardian name

Parent contact information address (Number, Street, Apt#, City, State, Zip Code)

Parent Phone Number (Area Code) Number

Parent email address

Is student diagnosed with a disability Is student diagnosed with a disability

Yes

Does the Student have now or ever had in the past? Does the Student have now or ever had in the past?

IEP

504 Plan

Health Care Plan

Is Student enrolled with any agencies Is Student enrolled with any agencies

Yes

Major area of interest Major area of interest

Job Exploration Counselling

Work Based Learning Experience

Workplace Readiness Training

Post-Secondary Education Counselling

Self-Advocacy Training

What is the Student’s goal for Employment / Post-Secondary Education?

Reason for participating in project

 I would like to apply for Pre-Employment Transition Services administered by Pre-ETS  I would like to apply for Pre-Employment Transition Services administered by Pre-ETS

Yes

Parent/Guardian or Student who is 18 or older

Clear

Signature Date

Consent to Share Information

I, give permission for the staff and partners of Pre-ETS WORKS -Erie and Adult Career and Continuing Education Services - Vocational Rehabilitation

(ACCES-VR) authorization to obtain/release Information (including school records, disability information and status of ACCES-VR process) to share information about me, my program and my progress in said program in order to assist me in Pre-ETS planning and coordinating services necessary to complete Pre-ETS activities.

I understand that I may revoke this permission at any time, in writing, to the Pre-ETS WORKS - Erie.

Consent to Share Information Consent to Share Information

Yes

Parent/Guardian or Student who is 18 or older signature

Clear

Date signed

Consent to Release Records

I, request the following records pertaining to be released by to Pre-ETS WORKS - Erie, c/o Erie 1 BOCES; 355 Harlem Road, West Seneca, NY 14224 and Adult Career and Continuing Education Services-Vocational Rehabilitation (ACCES-VR) authorization to obtain/release Information (including school records, disability information and status of ACCES-VR process) for the purpose of (see the next question)

Consent to release records for the purpose of Consent to release records for the purpose of

Pre-ETS WORKS enrollment

Programming decisions of Pre-ETS WORKS Project

Other

Records released Records released

Current IEP

Current 504 Plan

Current Health Care Plan

Last IEP / 504 Plan / Health Care Plan If no current plan in place

Transcript

Other (specify)

Parent/Guardian or Student who is 18 or older signature

Clear

Date signed

Consent to Share Photos

I, give permission for the staff and partners of the Pre-ETS WORKS - Erie to utilize the photos of and/or myself in presentations and for training purposes for the Pre-ETS Project.

I understand that I may revoke this permission at any time, in writing, to the Pre-ETS WORKS – Erie.

Parent/Guardian or Student who is 18 or older signature

Clear

Date signed

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Welcome