To download the 2018 Youth Career Camp application, click here

To apply online, fill out the form below.

Youth Career Camp Online Application
*Please check which program session applies::
Applications are due June 25, 2018 for the first session, and July 6, 2018 for the second session.
I. Participant Information
*Gender:
mm/dd/yyyy
*U.S. Citizen?:
*Are you a VR client?:
*Currently resides:
*Legal Status:
Available characters remaining:
(this information is required by a funder, but does not determine eligibility)
II. Medical Assessment
Enter client diagnosis. Refer to evaluations and/or support plans
*a. History of illness and physical limitation/restrictions (Clarify as applicable in text box below)::
Available characters remaining:
Available characters remaining:
Please include medication name, dosage, time(s) taken, date prescribed, prescribing physician and reason
*c. Is Participant able to self-administer medications?:
List details
III. Behavioral/Adaptive Skills Assessment
Please give details of exhibited behavior in the fields below. If participant does not exhibit a behavior, please mark "n/a" in the field.
Available characters remaining:
Specify frequency, duration, example of specific behaviors, and possible triggers and/or circumstances under which behaviors occurs
Available characters remaining:
Specify frequency, duration, example of specific behaviors, and possible triggers and/or circumstances under which behavior occurs
Available characters remaining:
Specify types i.e. being touched, loud noises, enclosed spaces, etc.
Available characters remaining:
Specify types i.e. not following directions, etc. specify frequency and circumstances under which behavior occurs.
Available characters remaining:
Provide details and attach background information, if applicable.
Please estimate applicant’s ability level in each daily living area, check appropriate number and explain your answer. 1= Can complete task independently with no assistance. 2= Can perform this task with some limited support. (please explain) 3= Can only partially perform this task and/or needs much assistance. (please explain) 4= Cannot perform this task at the present time.
*1. Applicant’s ability to toilet self and maintain toileting hygiene::
*2. Applicant’s ability to move from one area to another with or without assistive devices::
*3. Applicant’s ability to eat; including feeding self, chewing, swallowing, cutting, using spoon, etc.:
*4. Applicant’s ability to self-administer medication::
IV. Educational History
Name of High School
mm/dd/yyyy
Standard, GED, special diploma, certificate of attendance, etc.
Enter Info. For Post-Secondary or Trade/Technical School
V. Employment History
Name and title of supervisor
mm/dd/yyyy
Earnings per hour
Earnings per hour
List hours
State reason for leaving, ex. relocated, laid-off, terminated, etc.
VI. Demographics
(Voluntary response is requested. This information is collected for general reporting purposes only.)
*Demographics:
VII. Additional Information
*Please note: The following documents must be attached to or submitted with this application in order for the program staff to make an acceptance decision.
Accepted File: DOC,PDF,DOCX,TXT,RTF
Accepted File: GIF,JPG,PNG
Accepted File: DOC,PDF,DOCX,TXT,RTF
Accepted File: DOC,PDF,DOCX,TXT,RTF
Accepted File: DOC,PDF,DOCX,TXT,RTF
If you have any questions or comments regarding this application or need assistance with this application please contact the Program Manager at (954) 746-9400

PARTNERS

 

Address: 10250 NW 53rd Street Sunrise, Florida 33351 Phone: (954) 746-9400