Thurston/Mason County Developmental Disabilities

Job Foundation/School to Work Application

To complete this application, a supported employment provider selection is required. Please make sure you have identified the agency you want to work with before beginning. Once you begin this application, there is no way to save your progress and return later.

Applicant Information

Student's Name *

Program you are applying for *

Job Foundation

School to Work

Birthdate * +

County *

Thurston

Mason

Do you have a guardian? *

If yes, guardian's name

Street Address *

City *

Zip Code *

Primary Language *

Would you like an interpreter?

Do you use American Sign Language?

School Information

School *

District *

What is your final year of school? * 🛈

Teacher's name *

Parent/Guardian Contact Information

Parent 1/Guardian 1 Name *

Phone Number *

Cell Phone *

Yes

Relationship *

Email *

*Please note, you may be sent an encrypted email, if the email contains the student's name or personal information.

How do you prefer to be contacted? *

Phone Call

Text

Other Representative

Phone Number

Cell Phone

Yes

Relationship

Services information

Are you a client with Developmental Disabilities Administration (DDA)? *

Yes

Unsure

Have you applied to Division of Vocational Rehabilitation (DVR)? *

Yes

Unsure

Do you receive Supplemental Security Income (SSI)/Medicaid? *

Yes

Unsure

Have you ever received benefits planning? *

Yes

Unsure

I would like help applying for

DDA

DVR

SSI/Medicaid

Acknowledgement of Understanding

Please carefully read each of the following and type your initials to acknowledge your understanding.

Eligibility criteria:

Eligible for Developmental Disabilities Administration (DDA) services.
19-20 years of age for Job Foundation; or 20-21 years of age for School to Work.
Enrolled in a Thurston/Mason County school district. Note: Student must remain enrolled in school throughout the program.
Committed to finding a job before exiting the last year of school.
Have obtained or are willing to apply for:
- SSI/Medicaid benefits
- Washington State ID
- Division of Vocational Rehabilitation (DVR) services

Initial acknowledging: The student meets all eligibility requirements *

Students are encouraged to interview a minimum of two employment support providers and select a provider as early in the application process as possible to ensure services are delivered in a timely manner. This is a working relationship that will continue throughout the time the student is participating in the Job Foundation and/or School to Work program(s), so make sure the provider is a good fit for you.

Initial acknowledging: Students are encouraged to interview a minimum of two employment support providers. *

This program requires a team approach. Key team players include: the student, parent/guardian, employment support specialist, teacher/school staff, DVR counselor, DDA case manager, and County High School Transition Coordinator. The team is expected to meet approximately four times during the year, or as needed, and all team members are expected to attend.

Initial acknowledging: This program requires a team approach. *

Students are expected to develop a reliable transportation plan, outside of school transportation, to get to their job on time, as this will be required once school services are completed. Possible options for transportation are family/friends, community bus, Dial-a-Ride/Dial-a-Lift.

Initial acknowledging: Students are expected to develop a reliable transportation plan. *

Work schedules may include evening and/or weekend hours. Students may be expected to go to work even if there is a school closure due to weather, holidays, early dismissal, etc. Students need to make work a priority and schedule school and recreational activities around their work schedule. Students and their support team need to communicate directly with employers if they are sick, late, or wish to request time off for vacations or special events. Please update your team in advance of extended vacations.

Initial acknowledging: Work schedules may include evening and/or weekend hours. *

The Job Foundation and School to Work programs do not guarantee that all students will leave school with a job. These programs provide an opportunity to work toward this goal while the student is still in school. Even if a student does not exit school with a job, the student will have acquired work skills to help in obtaining and reaching his/her employment goals.

Initial acknowledging: The Job Foundation and School to Work programs do not guarantee that all students will leave school with a job. *

This program does not guarantee the availability of long-term funding. The program is funded by Thurston/Mason County Developmental Disabilities using limited County funds through the end of the school year only. DVR is a funding partner for School to Work; however, they do not provide funding for long-term support. This support can be critical to maintaining employment and can be essential to building a career path. Each student and/or their parent/guardian is required to learn about their long-term funding options, which is funded by DDA waivers.

Initial acknowledging: This program does not guarantee the availability of long-term funding. *

Consent/Authorization

Thurston/Mason County Developmental Disabilities
Consent to Share Information

Thurston/Mason County Developmental Disabilities works with the Developmental Disabilities Administration (DDA), Division of Vocational Rehabilitation (DVR), and various local organizations to provide employment and other supportive services to adults with developmental disabilities and their family members. By signing this form, you are giving permission for the County and the agencies and individuals listed below to share information so that we can work as a team to help you achieve your goals.

Consent

I consent to the sharing of confidential information about me for the purpose of helping me with planning, service coordination, and resource identification. I further grant permission to Thurston/Mason County Developmental Disabilities staff and the below listed agencies, organizations, or persons to use my confidential information and disclose it to one another for these purposes. Information may be shared by computer data transfer, mail, hand delivery, or verbally.

DSHS Divisions and Administrations including but not limited to, Developmental Disabilities

Administration (DDA), Division of Vocational Rehabilitation (DVR), Children’s Administration,

Financial Services, Office of the Deaf and Hard of Hearing (ODHH), Department of Services

for the Blind (DSB), etc.

School District (write in) *

Parent/Guardian Name(s) (write in) *

Supported Employment Provider (select one): * 🛈

Centerforce (Thurston County only)

EFI (Mason County only)

Morningside

Vadis

Other individuals or agencies we may share information with. (write in) 🛈

I authorize and consent to sharing of the following records and information:

Name, address and phone number
Information pertaining to my educational experience
Information pertaining to training or employment

PLEASE NOTE: If your confidential records include any of the following information you must also complete this ‘Special Records’ section to allow disclosure of these records.

Special Records: I give permission to disclose the following records (check all that apply):

HIV/AIDS and STD test results, diagnosis, or treatment records (RCW 70.24.105)

Mental health records (RCW 71.05.620)

Chemical Dependency (CD) records (42 CFR Part 2)

Community Protection

Notice to those receiving information: If these records contain information about HIV, STDs, or alcohol or drug abuse, you may not further disclose that information under federal and state law without specific permission of the subject and meeting specific requirements.

This consent is valid until no longer necessary *

Yes

If No was selected above, please select a date this consent is valid until +

I understand that I may revoke or withdraw this consent at any time in writing, but that will not affect any information already shared. A copy of this form is valid to give my permission to share information.

Signature

Date Signed +

Student Signature (if student is 18 or older and their own guardian)

clear

Legal Guardian/Representative Signature (if applicable)

clear

Guardian/Representative Name:

I am the

Student

Legal Guardian

Representative Payee

Other Other