Project SEARCH Dane County 2016-2017 APPLICATION
Information
NAME: Click here to enter text.
DATE: Click here to enter text.
Project SEARCH Intern Profile
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Enrolled in a Dane County School District.
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Able to actively engage in a 30 hour work
week with good attendance.
Eligible for DVR services.
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APPLICATION STEPS
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February 20 - Application deadline
Complete and Submit Project SEARCH
Application.
- School records: Current IEP, Behavior Support
Plan, Last Evaluation.
- Confirmation of DVR application.
- Confirmation of Dane County ADRC
application.
February 27
Mandatory Skill Assessment Day. UW Hospital.
Plan a full day. Completed independently by
applicant.
March – Gather additional information,
schedule observations as needed.
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Eligible for long term adult support with
Dane County (a limited # of applicants
may be admitted who are not eligible for
long-term support).
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Wants to transition out of K-12 education
following SEARCH internship.
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Wants to work in a hospital or health care
setting.
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Independently manages meals and all
personal cares (with or without
accommodations.)
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Independently meets hospital hygiene
policies and infection control
requirements.
Has a history of interacting with people
appropriately and respecting others'
property.
Takes direction from supervisors and
modifies behavior as needed.
Aged 18 to 21 and has completed 4 years
of high school.
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AFTER ACCEPTANCE and PRIOR TO SEPTEMBER 1
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April –IEP meeting to add summer services and
change placement starting Sept 2016.
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June - Attend Project SEARCH parent meeting
before end of 15-16 school year.
Summer - Participate in any necessary ESY
services.
- Provide updated immunization records.
- TB tests are required prior to working at the
UW Hospital as part of the New Employee
Orientation Process.
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Able to get to and from Project SEARCH
daily (note: Special Education
transportation does not operate to
UW/VA Hospital site)
Can commit to year-long program to
include summer 2017.
Submit Applications to:
March 31 - Acceptance/Regrets letters are
sent out.
Marcia Ingvalson, Project SEARCH
Madison Metropolitan School District
Department of Student Services
545 W. Dayton St. Madison, WI 53703
or Email to: ProjectSEARCH@madison.k12.wi.us
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Project SEARCH Application
Application should be completed by student with support from parents/guardians, and/or teachers only
as needed. It is strongly encouraged that student will have attended the Project SEARCH Information
Session, toured Project SEARCH and/or watched the Project SEARCH video prior to completing this
application.
Name:
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Address:
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Phone Number: Click here to enter text.
Email address:
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Birthdate: Click here to enter text.
Parent / Guardian: Click here to enter text.
Address: Click here to enter text.
Phone Number:
Email:
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Preferred method of contact: Click here to enter text.
Parent / Guardian: Click here to enter text.
Address:
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Phone Number:
Email:
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Preferred method of contact:
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Do you have a guardian? (check one) ☐ Yes
If yes, Guardian name:
Address:
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Phone Number:
Email:
☐ No
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Preferred method of contact:
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☐ In Process
Have you been approved for services with DVR? (check one)
☐ Yes
☐ No
☐ In Process
Name of DVR Case Manager or Contact Person: Click here to enter text.
Have you been approved for Dane County Adult Services? (check one)
☐ Yes
☐ No
☐ In Process
Name of Dane County Case Manager or Contact Person: Click here to enter text.
EDUCATION:
Will you have completed four years of high school by the end of this school year?
☐Yes
☐No
Name of High School: Click here to enter text.
Name of Case Manager:
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Case Manager Email: Click here to enter text.
What classes are you taking this year?
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EXPERIENCE:
(Include volunteer, non-paid training, paid employment)
Location
Length of
Experience
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Duties
Supervisor
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PERSONAL STATEMENT:
In your own words, why do you want to be a Project Search intern?
(If this section is scribed, please write exactly the words used by the candidate.)
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Signature_______________________________________ Date (click here, then down arrow for date)
Thank you!! You will receive email confirmation when your application is received.
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