Positive Vibe Training Program Application
Please complete the following application.
Applicant Name *
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Date of Birth *
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Sex *
Race *
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High School and Grade or Date Graduated *
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Applicant's Address *
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Applicant's Phone Number *
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Applicant's Email Address
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Parent/Guardian *
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Parent/Guardian Phone Number *
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Parent/Guardian Email Address
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School IEP Case Manager: Phone Number & Email
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DRS or CBS Case Manger/ Counselor: Agency, Phone Number, & Email
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Most recent IEP/ Evaluation Date
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Applicant's Disability & Needed Adaptions *
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Medication/Allergies *
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Applicant Info *
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Previous Employment
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Volunteer/ Training Experience
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Schedule Conflicts
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Emotional Issues/ History
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Emergency Contact: Name, Phone Number & E-mail *
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Does the student have any communication/technology needs? if so, what?
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Does the student have any disruptive personal or classroom behavior(s)? if so, what?
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Is the student blind, or have a visual impairment? *
If the student deaf, or have an auditory impairment? *
What are the student's employment or education goals?
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Accommodations that work
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Notes:
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How did you hear about PVC Training?
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