Pre-ETS Packet

82 Washington Street Suite 209

Poughkeepsie, NY 12601

Pre-ETS Youth Referral Form

To be completed by Student/Parent or Guardian

Student Name: ______________________________	DOB: ___________________		Age: __________
*Social Security Number: _______________________________________	Gender:  Male  Female  Prefer not to disclose __________________ (fill in the blank)
School: _________________________	Grade: ________________________________
Parent/Guardian Name: _____________________	Home and/or Cell #: ____________________________
Address: __________________________________ __________________________________	Email: ____________________________________
Preferred pronouns:  He/His  She/Her  They/Them	Do you have any food allergies?  Yes  No
Please specify your ethnicity:  White  Hispanic or Latino  Black or African American  Native American or American Indian  Asian / Pacific Islander  Other:  ______________________________
Please select your eligibility.  IEP  504 Plan  Medical Documentation  Other		Do you have an active case with ACCES-VR?                                                Yes     No

 

Referral Source: ______________________	Phone: _________________	Referral Date: __________
Referral Agency/School: ____________________________________________________________________
Benefits: The PRE-ETS Program aims to prepare students for life after high school and successful long-term employment consistent with their strengths, abilities, interests, and informed choices. The following topics will be covered: Job Exploration Counseling Workplace Readiness Training Self-Advocacy for Students Work-based Learning Experience Counseling on Post-Secondary Opportunities for Students ALL STUDENTS ARE ENCOURAGED TO COMPLETE ALL ACTIVITIES

 

 

 

 

 

 

 

 

For Parent/Guardians

PRE-ETS PROGRAM PARENT CONSENT FORM

 

I understand that this is not an application for services from ACCES-VR. Pre-ETS Program is committed to good privacy practices. Pre-ETS Program requires access to personal information about you, which will be maintained by Pre-ETS Program.

 

By signing this form, you are authorizing Pre-ETS Program to access any personal information to determine eligibility to receive Pre-ETS services.

 

Please note that Pre-ETS Program will continue to protect confidential information maintained about you from release to the public or other unauthorized parties.

 

I hereby give Smart Staffing Group permission to disclose information relating to my child to the Adult Center and Continuing Education Services-Vocational Rehabilitation (ACCES-VR), including disability information.

 

*Parent/Guardian Signature: __________________________________                       Date: ______________________

 

*Student Signature: __________________________________                                     Date: ______________________

 

Pre-ETS Program Supervisor Signature: _________________________        Date: ______________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All potential clients please be aware that our questions on this referral form are designed to serve our clients with the best services available by our agency.

 

We respect and are sensitive to all race, gender, and cultures in our community.

 

We as an agency would never practice discrimination or bias on the grounds of race, sex, or cultural differences.