Advanced Leadership & Career Development Program (ALCD Program)

A 2-year Advanced Certificate Program

Student Application Packet

For Fall 201_

All applications will be reviewed. Selected applicants will be invited to interview. Admissions are limited and based upon qualifications, available space,

and cohort composition. Otherwise qualified applicants may be turned away based on these factors.

KSU Academy ALCD Program Kennesaw State University

520 Parliament Garden Way, NW Kennesaw, GA 30144

The KSU Academy ALCD Program is available to unique learners who are highly motivated young adults and have received a certificate of successful completion from The KSU Academy for Inclusive Learning and Social Growth ASCE Program or comparable Inclusive Post-Secondary program at another institution. Please send the finished application to academyadmissions@kennesaw.edu or mail to the address above.

Applications will be accepted each fall for the KSU Academy Advanced Leadership & Career Development the next year’s cohort.

NOTE: Applications will not be considered unless ALL requested information is included.

The applications may be typed or printed neatly. Include all information (1-13 below). Recommendations must be submitted in a sealed envelope with signature across the seal.

1.

APPLICATION CHECKLIST Student/Family/History Information

2. Updated Medical History 3. 4. 5.

Release/Exchange of Information Form Proof and Acknowledgement of Guardianship signature page and document, if applicable Student Questionnaire to be completed by the applicant

6. Four (4) recommendations from persons who have known the applicant for at least one semester. Recommendations should not be completed by family members. The recommendations should represent each of the following:

(1) Academic recommendation (from previous college professor) (2) Vocational/employment recommendation (from previous job site,

volunteer or paid) (3) Community involvement recommendation (4) Character recommendation (Those applying from outside the Academy may wish to use their IPSE staff)

****Recommendations must be submitted using the Recommendation Forms in this packet and must be returned with the application packet in sealed envelopes as directed on the form.

7. 8.

paper) 9. 10.

Resume Two (2) graded academic samples from previous classes (i.e. artwork, presentation, typed Copy of the most recent IEP Copy of results of a current psychological evaluation

11. Official high school transcript 12. Official post-secondary transcript 13. Results of a current physical exam

Applicant’s Signature _Date

Parent/Guardian Signature Date

1

STEP 1

Application Process

Print out Letters of Recommendation STEP 2 Complete and submit the Student Application Packet (including all information from checklist) Submit Letters of Recommendations (4 total; see checklist and evaluation forms for details) STEP 3 Upon receipt and review of the completed application packet, documents will be reviewed. The review committee will determine whether the applicant will be contacted to schedule a personal interview

Application Selection Process Applications and supportive material are reviewed by an admissions committee and serve as the basis for the selection process. An interview or meeting with members of the admissions committee may also be required. Please do not call about the status of your application, as we will not be able to provide this information for you over the phone. You will receive an email or letter regarding your status. Qualifying applicants will receive official notification of the decision of the admissions committee via email and traditional mail Note: A limited number of applicants will be admitted for the each cohort. Admissions decisions are taken very seriously and consideration is based on a wide range of criteria including, but not limited to assessment of the strengths of each applicant, available space and cohort attributes.

The decision to offer or deny admission to the program will be made by the Admissions Committee in their best judgment and in the best interests of the applicant. Admission will be based on the following criteria:

The applicant must have successfully completed requirements for the Certificate of Social Growth and Development (ASCE Program) from the KSU Academy for Inclusive Learning or comparable inclusive post-secondary program. Applicant must be in good standing with the conferring institution

The applicant must provide documentation of a significant cognitive and /or developmental disability that interferes with their academic performance (AAIDD definition)

The applicant must demonstrate sufficient emotional and independent stability to participate in all aspects of the KSU Academy ALCD Program including coursework and campus environment

The applicant should be able to sit through 90 minute courses and function independently for 2 hour blocks of time

The applicant must demonstrate the ability to accept and follow reasonable rules and behave respectfully towards others. Note: The Academy ALCD Program does not have the personnel to supervise students with difficult and challenging behaviors or to dispense medications

The applicant must demonstrate the desire to attend the KSU Academy ALCD Program and adhere to all Kennesaw State University policies and procedures

The applicant must have the potential and the desire to be successful in competitive employment situations

The applicant must have scored a 7 or higher on most recent PMC in all areas, or provide comparable documentation of independent functioning from previous inclusive post-secondary program

Please complete all sections of this application (pages 3-14). It is acceptable for the applicant to receive support, if needed, in completing this section of the application. You may attach additional information and pages for writing space if needed. All information is confidential and will not be shared with any outside agencies unless required by federal or state law, or a written agreement is provided by those filling out the application. Please send the finished application to academyadmissions@kennesaw.edu or 520 Parliament Garden Way, Kennesaw, GA 30144.

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3

*This is a Certificate Program NOT a degree-conferring program from Kennesaw State University.

Please contact the Academy office at academyadmissions@kennesaw.edu if you have any other questions. STUDENT INFORMATION

Last Name First Name MI

Home Phone Cell Phone

Address

City State Zip Code

Birth date

I identify as a Male/Female/Other

Email address

Student receives support or services from: (please check those that apply)

Supplemental Security Income

Medicaid Waiver

Social Security Disability Insurance

Division of Vocational Rehabilitation

Are you currently on an active Vocational Rehabilitation caseload? Yes No

If yes, what is the name of your VR counselor?

Contact information:

What services have been provided to date?

4

FAMILY INFORMATION

Applicant lives with:

Both parents Mother _ Father Guardian(s) Other

Mother/Guardian:

Last Name First Name_ MI _

Home Phone Cell Phone

Address

City State Zip Code

Occupation/Employer Work Phone

Email address

Father/Guardian:

Last Name First Name MI _

Home Phone Cell Phone

Address

City State Zip Code

Occupation/Employer Work Phone

Email address

Siblings:

Name: Age:

EMERGENCY CONTACT INFORMATION: IN CASE OF AN EMERGENCY, PLEASE CONTACT…

at (Name) (Phone)

OR at (Name) (Phone)

5

Summary of Previous College Experience

Audited Courses Completed at (college name) begin with most recent

Semester Course Number Course Title Professor

List any additional courses on a separate page

For Credit Courses Completed at (college name) begin with most recent

Semester Course Number Course Title Professor

List any additional courses on a separate page

List of Certificates Earned begin with most recent

Certificate Name Conferring institution

Date Comments (optional)

Clubs, trainings, or other experiences

Organization name Date Comments (optional)

6

EMPLOYMENT HISTORY Please complete the following. Please include internships, job shadowing experiences, volunteering, and paid employment.

Name of Business/Employer

Paid or Unpaid

Job Responsibilities Reason for Leaving

Dates

Are you currently participating as a volunteer? if yes, please list details:

What work experiences do you have an interest in or enjoy?

TRANSPORTATION How do you plan to travel to off-campus locations?

What plans will you make for recreational, social, and leisure opportunities?

Are there any limitations, support needs or related issues to transportation? (Please List)

Note: The Kennesaw State University Academy for Inclusive Learning is unable to provide transportation to and from the campus.

7

UPDATED MEDICAL HISTORY

Please give a brief description of your medical history including any disability diagnoses:

Please list any significant medical or physical conditions that may affect your participation in classroom, social, or recreational activities on campus, including severe allergies:

Please list any current medications, dosages and their specific application:

Note: If the applicant must take medications while on campus, he/she must be independent in administering his/her medications. Kennesaw State University and the KSU Academy ALCD Program do not have the personnel or facility to administer medications.

Do you currently receive private therapeutic services, such as physical therapy, occupational therapy, psychiatric therapy, speech therapy, or behavioral therapy? If so, please indicate which services:

List any physical limitations:

Note: The applicant is responsible for providing personal assistance services, if needed, in order to attend Kennesaw State University.

Below, please provide any other medical information that you feel would be important regarding your participation in this program.

Kennesaw State University Academy ALCD Program

Release and Exchange of Information Form

Kennesaw State University treats and regards all written documentation obtained to verify a disability and plan for appropriate services as well as all documented services and contracts with the Office of Vocational Rehabilitation as confidential. However, it may be necessary for our staff to exchange some information about you with the Kennesaw State University faculty and staff in order to provide educational opportunities and experiences on and off campus. This exchange will occur only with your written permission, as given in this document below, and with the understanding that only information necessary for the purposes of accommodation and academic progress and work will be communicated.

Name

I give permission to exchange information about me to the following offices/individuals checked below: _School Personnel (list schools) _Department of Vocational Rehabilitation Office Work Sites and Field Experiences Supporting Agencies _Parents/Guardians _Tutor/Mentor _Other (Specify)

I agree, as part of the application process, to waive my right to access the completed student recommendation form.

.

Applicant Signature Date

Parent/Guardian Date _

Witness Date

8

Kennesaw State University Academy Leadership & Career Development Program

Proof and Acknowledgement of Guardianship

This is to acknowledge that even though my child is over the age of eighteen (18), I am his/her legal guardian.

I have attached a copy of the court-ordered guardianship.

Parent/Guardian Signature

As the applying student, I acknowledge that legal guardianship resides with my parents and that all documents and information from Kennesaw State University will be shared with them.

Applicant Signature

OR

I am my own legal guardian.

Applicant signature

9

APPLICANT QUESTIONNAIRE

This section is to be filled out by the applicant and may include additional pages. This is an excellent opportunity to demonstrate writing skills, critical thinking skills and creativity!

Why do you wish to be considered for the KSU Academy ALCD Program?

What goals do you want to achieve during the ALCD Program?

Give some examples of leadership experiences you gained during your previous Inclusive Post-Secondary Program?

What do you feel your strengths are?

What do you feel is your biggest challenge?

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RECOMMENDATION FORMS Please submit 4 Recommendations from persons who have known you for one semester or longer. Recommendations should not be completed by family members. The recommendations should represent each of the following:

(1) Academic recommendation (from previous college professor) (2) Vocational/employment recommendation (from previous job site, volunteer or paid) (3) Community involvement recommendation (4) Character recommendation (Those applying outside from the Academy should use their IPSE staff)

Kennesaw State University Academy ALCD Program

Recommendation Form

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12

Recommendation for (Applicant’s name)

The above named individual is applying for admission to the Kennesaw State University Academy of Inclusive Learning and Social Growth ALCD Program. This program is designed to provide students with developmental disabilities a strong system of support academically as well as developing advanced career training and leadership skills. Successful applicants are highly motivated young adults who have received a certificate of successful completion of the ASCE Program at the KSU Academy for Inclusive Learning and Social Growth or a similar inclusive post-secondary program. Applicants should have demonstrated the potential to become an independent adult as well as the emotional stability and maturity to participate successfully on the KSU campus.

With the above information in mind, please answer the following questions to the best of your ability and complete a Personal Support Inventory (attached). Attach additional pages as needed. Please return this form to the applicant in a sealed envelope and sign across the seal. The applicant has agreed, as part of the application process, to waive access to the recommendation form. The applicant will submit all letters of recommendation as part of their completed application packet. Thank you for your assistance in this matter.

Your name Last First MI Title

Address Street Apt #

City State County Zip

Organization Name Phone #

1. How long have you known the applicant and in what capacity?

2. Please describe why you feel the applicant would benefit from participation in the KSU Academy ALCDProgram.

3. Please describe the strengths that the applicant may have, or challenges overcome, that will makehim/her a strong candidate for this program? (Use the back of this page or attach additional pages as needed)

13

Social Skills and

Communication 1 (Requires Complete Assistance)

2 (Needs moderate assistance)

3 (Needs some assistance)

4 (Needs minimal assistance)

5 (Completely Independent)

Demonstrates confidence and conversational skills

Engaging in appropriate social interactions

Use of problem solving strategies

Demonstrates appropriate conflict resolution skills

Makes informed decisions/avoids peer pressure

Demonstrates motivation for personal growth

Academic Skills 1 (Requires Complete Assistance)

2 (Needs moderate assistance)

3 (Needs some assistance)

4 (Needs minimal assistance)

5 (Completely Independent)

Handling money: counting change/bills, understanding values, using bank account

Schedules an appointment with professor to ask for assistance/clarification/information

Independently completes modified course assignments and other academic tasks

Computer Skills: Proficiency in Word processing, Internet, D2L, Email

Motivation to learn and persist on new tasks

Knows and can verbalize and/or write personal information: name, address, phone, student ID, etc.

Ability to follow verbal directions

Ability to follow written directions

Ability to keep a daily schedule with due dates and assignments

Has applicant utilized any assistive technology? If yes, what?

14

Career Skills 1 (Requires Complete Assistance)

2 (Needs moderate assistance)

3 (Needs some assistance)

4 (Needs minimal assistance)

5 (Completely Independent)

Develops a plan to achieve realistic career goals

Punctual

Acknowledges and accepts supervision or correction

Demonstrates appropriate conversational skills

Motivation to learn and persist on new tasks

Demonstrates professional vs. personal relationships

Ability to follow verbal directions

Ability to follow written directions

Manages time and work tasks appropriately

Demonstrates appropriate work appearance

Follows work schedule

Asks for assistance when necessary

Attends to detail and quality of work

Additional information: