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CVFW9aETIXtIBuvm8uNgnMCm6czEmkiXoddkuBVzKX2CugM

Bridge to College Application

Returning?

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Please complete the application below for Propel Bridge to College Program. We will only consider candidates who fill out the application completely. Applicants should have a Parent or Guardian help fill out this application.

We are looking for candidates who are 18 to 25 years old with an intellectual disabilty who have an interest in exploring careers and education.

This application should take 15 to 30 minutes to complete. If you need to stop for any reason you can select "Save and Return Later" at the bottom of the screen. You will need to write down the return code and use that to access your partially completed application. The "returning" option is in the upper right hand corner of this screen.

Text to Speech is available and can be selected in the upper right hand corner of this page. When enabled, icons will be displayed next to all text on the survey page, and when clicked, the text will be read out loud to the applicant. (You must have your computer speakers or headphones on.)

If you are having trouble with the application you can email Kate Duffy at duffymp@umkc.edu. Please save what you have, and Kate will get back to you as soon as she can.

Remember, we will only be accepting complete applications.

Thank you!

First Name

* must provide value

Last Name

* must provide value

Gender

Male

Female

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Current Age

* must provide value

Date of Birth

* must provide value

M-D-Y

Address

Street Number

* must provide value

City

* must provide value

State

* must provide value

Zip Code

* must provide value

Phone Number

* must provide value

Alternate Phone Number

* must provide value

What high school do you go to, or what high school did you previously attend?

* must provide value

What is the highest grade you have completed in high school?

* must provide value

9th grade

10th grade

11th grade

12th grade

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Have you had any vocational training outside of high school?

* must provide value

Yes

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If yes, what vocational training have you received?

* must provide value

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Have you participated in career planning workshops?

* must provide value

Yes

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If yes, what career planning workshops have you participated in?

* must provide value

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Do you have a job?

* must provide value

Yes

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Is your job a paid position?

* must provide value

Yes

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Who is your employer?

* must provide value

What are your basic job duties of your current job?

* must provide value

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The following information is optional for you to complete. It will be kept private. It helps us note diversity of Bridge to College participants.

Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

* must provide value

Yes, I am Hispanic or Latino

No, I am not Hispanic or Latino

Prefer not to respond

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How would you describe you race?

* must provide value

Multiple Race

White

Black or African American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

Prefer not to respond

The following information will be kept private. We do need to know about your disability for entrance into the Bridge to College program.

Do you have an intellectual disability?

Intellectual disability is defined as a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills. This disability originates before the age of 18.

* must provide value

Yes

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How would you categorize your intellectual disability? Please check all that apply.

* must provide value

Behavioral/emotional

Cognitive

Learning

Reasoning

Problem-Solving

Social Skills

Other

Please specify

* must provide value

How would you categorize your disability? Please select all that apply.

* must provide value

ADD/ ADHD

Autism

Health/ Medically fragile

Hearing

Mobility

Serious Emotional Disability (SED)

Specific Learning Disabilities (SLD)

Visual

Other

Please specify

* must provide value

What are your goals and dreams in life?

* must provide value

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Why do you think Propel Bridge to College would be helpful to you and what do you hope to gain?

* must provide value

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Please provide below a school contact person that you can use as a reference. This can be a teacher, school counselor, or someone who can speak about some of the work you have done in high school.

Contact Name

* must provide value

Job Title (e.g. counselor, teacher)

* must provide value

School Contact Telephone

* must provide value

School Contact Email

* must provide value

Which day of the week would you be available to attend the Bridge to College program (select all that apply)?

Tuesday

Thursday

Please provide a brief description of your child's intent to attend college and employment goals. Please provide 2-3 sentences on these goals.

Note: We are not judging grammar or sentence structure on these questions. We would just like to hear your goals for the student.

* must provide value

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I understand that to earn the Propel Bridge to College certificate of completion, I must attend all sessions, complete assignments and be an active participant. It will be my responsibility to act appropriately, just as I would at a place of employment or school.

I understand that Propel Bridge to College staff and leaders will determine what appropriate behavior is, and I agree that I will participate fully, behave appropriately and act respectfully toward those with whom I participate and work. Regardless of age, I agree I will not have in my possession or use anything which is or could be considered a weapon; any type of explosive devise including firecrackers; and chemicals of any kind including, but not limited to, tobacco, alcohol or any other drug, unless they are listed on my medical form as prescribed medication. I understand that cell phones are to be turned off during meetings, events or trips. I understand that if my behavior is deemed to be disruptive or destructive, I may be asked to leave and will forfeit my certificate of completion.

* must provide value

Add signature

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.