Program for Successful Employment Application

First Name

Middle Initial (If you have no middle name put "N/A")

Last Name

Suffix

Semester Applying For:
Fall 2024
Spring 2025

Gender
Female
Male

Date of Birth

Ethnicity:
African American
White
Asian
Native American
Hispanic
Other

If other was selected, please include here.

Please select Exceptionality or Disability (if more than one select all that apply.)The Program for Successful Employment (PSE) is a two-year vocational training program for adults with autism and/or other cognitive disabilities.
This field is Autism/ Autism Spectrum Disability (ASD)
Intellectual and Developmental Disability (IDD)
Cerebral Palsy
Down Syndrome
Mental Health Disorder
Other

Applicant's Current Physical Address

Current City

Current State

Current Zip

Applicant's Primary Phone Number

Applicant's Cell Phone Number

Applicant's Email Address (if no email, please put N/A)

Parent(s) or Guardian(s) Information

Contact First Name:

Contact Last Name:

Relationship to Applicant

Contact Phone Number

Alternate Phone Number

Contact Email address

This person can be contacted in regards to my application.
Yes
No

Name and location of current or last high school attended?

If currently enrolled, list current grade and date of anticipated completion. (Ex:12th, May 2020)

Did you complete High School with a
Diploma
HiSet or GED
Certificate of Achievement
Currently enrolled in high school

If yes to completion of high school, what year did you graduate?

Did you have an IEP ( Individual Education Plan) or 504 plan while in school?
Yes
No

Have you ever taken any college courses?
Yes
No

Name of College or Vocational School

Year(s) attended?

How many Credits earned?

Have you used assistive technology?
Yes
No

If yes, please explain the assistive technology you used.

Why do you want to participate in the Program for Successful Employment at BRCC?

Do you currently have a paid or volunteer job?
Yes
No

Do you have a driver's license?
Yes
No

How will you get to BRCC and work? (Check all that applies)
Parent
City Bus
Car
Cats on Demand
Other

If other, please indicate.

Do you meet the above requirements?
Yes
No
Most of the requirements

If accepted, I acknowledge part of my vocational training will include participating in an unpaid externship. I agree to participate.
Yes
No

If accepted, I agree to participate in one benefits counseling session with a benefits counselor to discuss how working will/could possibly affect any government benefits I qualify for.
Yes
No
Not Applicable- I do not receive benefits.

If accepted, I agree to follow the rules established by PSE.
Yes
No

If accepted, I acknowledge that funding to cover expenses must be paid prior to my first day of class.
Yes
No

Applicant Signature