LifeWorks Bridge Academy @ KCTCS Application Who is filling this application out? * Applicant Family/Other Preferred Contact Method * Phone Email Applicant Information Applicant Name * First Name Last Name Applicant Date of Birth * MM DD YYYY Applicant Primary Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Applicant Email Address * Applicant Phone Number * (###) ### #### We will need your social security number but will get that from you separately. Parent/Guardian Information Parent/Guardian Name First Name Last Name Parent/Guardian Phone Number * (###) ### #### Parent/Guardian Email Address * KCTCS Information Which KCTCS campus do you attend or are planning to attend? * Ashland Big Sandy Bluegrass Elizabethtown Gateway Hazard Henderson Hopkinsville Jefferson Madisonville Maysville Owensboro Somerset Southcentral Kentucky Southeast Kentucky West Kentucky How long have you been attending? * You can respond with which year you are in or the semester you are in. Incoming Student 1st Year Student (in my first or second semester) 2nd Year Student (in my third or fourth semester) More than 2nd Year Student (in my fifth or higher semester) Student Status * Part Time Student (less than 12 credit hours per semester) Full Time Student (12 or more credit hours per semester) Participant Questionnaire Have you received or are you currently receiving service from the Office of Vocational Rehabilitation? * Yes No Unsure List any formal diagnoses. * Example: Autism, ADHD, etc. Select the Program Outcomes you are most interested in. Employability Each participant has the skills, habits, and self-confidence that allows them to obtain and maintain gainful, meaningful employment that is ideal to their unique interests and abilities. Housing & Transportation Each participant successfully obtains and maintains a safe, comfortable living situation in the community of their choice and can easily access transportation to the places they choose to go. Health, Wellness, & Nutrition Each participant has the awareness and basic skills to effectively manage their physical, mental, and emotional well-being. Also, the participant has the skills for selecting and preparing healthy, nutritious foods. Life Skills Each participant consistently performs routine daily living tasks with as much independence as possible and can demonstrate adequate executive functioning abilities. Relationships Each participant possesses the skills and self-awareness necessary to form and maintain friendships. Additionally, participants have the ability to interact, confidently and comfortably, with their employer, neighbors, and others. Financial Management Each participant successfully manages their money and other resources to maintain an independent living situation and to plan for their future goals. Adaptability Each participant has a willing and positive attitude toward continued learning and growth, and to practicing various skills even though it may seem difficult or uncomfortable at first. Personal Safety Each participant understands and practices basic methods for safety at home and in the community. Social & Leisure Each participant routinely initiates and participates in typical leisure activities, both individually and with others, that are meaningful to them. Employability Housing & Transportation Health, Wellness, & Nutrition Life Skills Relationships Financial Management Adaptability Personal Safety Social & Leisure What personal reasons does the applicant have for wanting to participate in the LifeWorks Bridge Academy? * Please list your personal reasons, not why your parents, teachers, or friends want you to. Why does the applicant think the LifeWorks Bridge Academy would be beneficial? * Examples may include developing independence skills, a community of peers, academic success, etc. Any additional information we should have about you or your desires to be a part of the LifeWorks Bridge Academy? Thank you!
