CAREER & COMMUNITY STUDIES
PARENT APPLICATION FOR ADMISSION
Please print or type legibly. If more space is required for responses, please attach an additional
sheet. You are encouraged to involve your student as a step towards helping him/her to take
ownership of the application process. Please keep a copy of the completed application packet for
your reference.
STUDENT INFORMATION
Student: Last Name
First Name
MI
Home Phone
Address
City
State
Email address
Zip
Birth Date
Cell Phone
Social Security Number (SSN)*______ ____ ______
*The applicant’s SSN and DOB are confidential and protected under federal law from
being disclosed to unauthorized parties. Your SSN will not be used as your applicant ID
number. Your SSN will be safeguarded by the University and the CCS Program and will
not be displayed on official records or made available to others.
Is the applicant a U.S. Citizen? ___Yes ___No If no, is the applicant a Permanent
Resident of the U.S.? ___Yes ___No
What language does the applicant speak?
Racial/ethnic information (Optional)
___Alaskan Native or American Indian
___Native Hawaiian or Other Pacific Islander
___African American/Black
General Application for Admission
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___Asian
___Hispanic/Latino
___White, not of Hispanic/Latino origin
How did you learn about the CCS Program at Kent State University?
___School Teacher/Counselor/Principal
___Flyer
___Service Provider
___Conference/Fair
___Internet Search
___Agency
___Other: explain
Student receives income, services, and/or support from: (please check all that apply)
_____Supplemental Security Income
_____Social Security Disability Insurance
_____Medical Assistance
_____Board of Developmental Disabilities (BDD)*
Counselor name
Email
Phone #
_____Vocational Rehabilitation (VR)*
Counselor name
Email
Phone #
_____Other*
Counselor name(s)
Email
Phone #
*If applicant receives services from VR, BDD, or other services, please provide counselor
name, email, and phone number.
General Application for Admission
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FAMILY INFORMATION
Student lives with:
_____Both parents
_____Mother
Mother: Last name
_____Father
First Name
_____Other _____Independent
MI
Address
Occupation/
Employer
City
State
ZIP
Email Address
Father: Last Name
Work Phone
Cell Phone
First Name
MI
Address
City
Home Phone
Home Phone
Occupation/
Employer
State
ZIP
Email address
Work Phone
Cell Phone
Please list any family members that are KSU Alumni/Current Students:
Names
Year Graduated
EMERGENCY CONTACT INFORMATION (2)
Name
General Application for Admission
Relationship
Phone
Page 3
Name
Relationship
Phone
EDUCATIONAL HISTORY – SECONDARY/POSTSECONDARY
Name of School
Location
Description of
Years Attended
Program (public,
private, transition, etc)
When did or will the applicant complete his/her high school education?
Did the applicant participate in general education classes through
K-12 education? ___Yes ____No
Did the applicant have an associate/aide in the regular classroom in high school?
___Yes ___No
If yes, how many hours per week?
If yes, what type of support did the associate/aide provide?
What other accommodations did the applicant utilize in the classroom?
General Application for Admission
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Did the student conduct his/her own IEP meetings? ___Yes ___No
If yes, describe how the applicant participated in his/her IEP meetings.
Briefly describe applicant’s academic strengths.
Briefly describe applicant’s academic weaknesses?
In the following areas describe what skills you would like the applicant to learn/improve?
Academics:
Vocational and Career:
Independent Living:
Social/Recreation/Leisure:
Does the applicant have access to a computer at home? ___Yes ___No
If yes, does the applicant use the computer? ___Yes ___No
If yes, approximately how much time a day does the applicant use a computer? _______
If yes, what applications or programs does the applicant utilize on the computer?
General Application for Admission
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SUPPORT SERVICES
Applicant: Please provide information on any related support services the applicant has
received in the past three years. Please give a brief explanation of services received.
Type of Service:
Occupational Therapy
___Yes ___No
Physical Therapy
___Yes ___No
Speech & Language
___Yes ___No
Assistive Technology
___Yes
Mental Health Services
___Yes ___No
Behavioral Therapy
___Yes ___No
___No
Other: (explain)
Has the applicant had any incidents of aggressive physical or verbal behavior in the past
three years? ___No ___Yes
If yes, please list the year and nature of the situation(s).
Has the applicant been arrested or had a restraining order against them? ___No ___Yes
If yes, please list the date and nature of the situation(s).
General Application for Admission
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Employer Site
EMPLOYMENT HISTORY
Paid or Job Responsibilities
Unpaid
Reasons for
Leaving
Amount
of time
at the
job
EMPLOYMENT HISTORY
Volunteer Site
VOLUNTEER/COMMUNITY INVOLVEMENT
Activities
Amount of
Time
If you are currently participating in a paid or unpaid work/volunteer experience, please
describe.
Please describe any school extracurricular activities the applicant has participated in the
past three years:
What are your goals for the applicant’s postsecondary education?
General Application for Admission
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Please list any effective supports that the applicant needed during major transitions
(transition into high school, moving to a new home, etc.).
Please indicate if the applicant has stayed overnight away from his/her primary
caregiver(s) in the past three years (camp, school, vacation, etc.). How did the applicant
manage?
What are your goals for the applicant concerning employment?
What are your goals for the applicant concerning independent living?
MEDICAL/DISABILITY HISTORY:
Physician’s Name and Name of Practice:
Address:
City
Office Phone:
Date of last
medical exam:
State
ZIP
Office Fax:
Does the applicant have problems with incontinence? ___No ___Yes
If yes, please explain.
Is the applicant independent in self-care such as toileting, and basic hygiene?
General Application for Admission
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Note: Applicants will need to arrange for personal assistance services, if necessary. This is
not included in any of the program or college services.
Does the applicant require any assistance in mobility: ___No ___Yes
If so, does the applicant use any of the following mobility aids?
___Prosthesis (specify)
___Braces
___Crutches
___Cane
___Manual Wheelchair
___Motorized wheelchair/cart
___Walker
Does the applicant require any canine assistance? ___No ___Yes
If yes, please explain.
Please give a brief description of applicant medical history (use additional pages if needed).
Include the impact on daily living that each medical condition may have on the applicant.
Please give a description of any disability diagnoses (use additional pages if needed).
General Application for Admission
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Please list any current medications and indicate the purpose.
Note: If the applicant must take medications while on campus, he/she must be independent
in administering his/her medications. Kent State University and CCS do not have the
personnel or facility to administer medications. This is not included in any of the program
or college services.
Has the applicant had a seizure in the past three years? ___No ___Yes
If yes, please explain and provide dates and medical treatment.
TRANSPORTATION/HOUSING
If accepted the applicant would: (mark all that apply)
___Commute from home both to and from campus
___Make arrangements to live independently in housing near campus (CCS does not
provide off-campus housing)
___Live in a dorm*
*Note: Applicant must complete a week-long summer independent living assessment to
ensure independent living readiness before being accepted into an inclusive University
dorm setting.
If necessary what are your plans for transportation to be used to attend the program?
General Application for Admission
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If necessary, will this plan allow for recreational, social and leisure opportunities to occur
after 3 p.m. and on weekends?
Note: Kent State University and Career & Community Studies are unable to provide
transportation to and from the campus.
ADDITIONAL INFORMATION
Please use this space to provide any additional information that you would like CCS to
know about the applicant pertaining to college admittance and participation.
I certify that all the information contained herein is complete and accurate; realizing that
any misrepresentation could result in disqualification from the application process.
Parent Signature
Date:
Parent Signature
Date:
General Application for Admission
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