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1PASSAGE USA APPLICATION PACKETUniversity of South AlabamaApplication for PASSAGE USAUniversity ofSouth AlabamaDepartmentofLeadership andTeacherEducation307. University Blvd., N Mobile, AL 36688-0002Phone:(251) 460-7558Fax:(251) 380-2758Email:passageusa@southalabama.eduPlease PRINT or TYPE allof theinformation requested.IDENTIFICATION INFORMATIONLEGAL NAME:LastFirstMs.Name Prefix:Mr.Mrs.Preferred First NameMiddleName Suffix: (Ex: Jr., Sr., III, etc.)OtherMaiden/Other NameADDITIONALIDENTIFICATIONINFORMATIONStudent Gender:FemaleMale Student Date of Birth:Student Social Security #*U.S. CitizenInternationalPermanent Resident / Resident AlienPlease choose one of the following **HispanicNon-HispanicRace** Choose any of the following:Black or African AmericanAmerican Indian or Alaska NativeWhiteNative Hawaiian or Other Pacific IslanderMarital Status:WidowedDid any of your family members graduate from USA?Are youa veteran?YesNoPlease contact theOffice ofVeterans Affairs at(251)460-6230 forbenefit information.ADDRESS (where USA should send your mailAddressApt.StateCityCounty of Legal ResidenceState of Legal ResidenceHome Phone Number (CountyZipCell Phone Number ()YesHas a guardian been appointed for you?)Work Phone Number (Do you live with your parent/ court appointed guardian?ParentGuardian I livebymyselfEmail (your preferred e-mail address)PARENT/GUARDIAN INFORMATIONPrefix:Mr.Mrs.Ms.)No What type of Guardianship?Other (Please Specify)FirstName: LastMiddle InitialRelationship to ApplicantApt. #AddressCityPhone Number (State)Check One:Email (your parent e-mail address)YesCurrentWorkCountyCellHIGH SCHOOL INFORMATIONHigh School from which you graduatedHigh SchoolLocation: CityHigh School Dates Attended: YearsHigh School Completion Date: MonthDid you receive a diploma?ZipNoMiddle School which you attendedMiddle School Location: CityMiddle School Dates Attended: YearsElementary School which you attendedElementary School Location: CityElementary School Dates Attended: YearsStateYearDid you receive a certificate of completion? YesIf yes, which type?MIDDLE SCHOOL INFORMATIONELEMENTARYSCHOOL INFORMATIONStateStateWORKEXPERIENCEEmployerJob TitleDatesNo
PASSAGE USA APPLICATION PACKETStart PayEnd PayHoursperJob DutiesJob TitleEmployerStart PayJob DutiesEndPayDatesHours perweekweek2
PASSAGE USA APPLICATION rnshipHours per weekTasks/DutiesDatesVolunteer/InternshipHours per weekTasks/DutiesDatesACCOMPLISHMENTSList one ormore things that you have done or a special skill you may steams,churchgroups,etc.INTERESTSListhobbies, specialinterest,travel,etc. thatyouenjoy most.REFERENCEPlease pick one teacher, who you know well, who has taught you at any phase of your education. Please see attached reference form.NamePhone numberJob ncomplete applications cannot be processed and will delay an admission decisionI declare that I am a United Sates Citizen. I understand that Alabama law provides that any person who knowingly makes a false, fictitious, or fraudulent statement orrepresentation regarding U.S. citizenship shall be guilty of a criminal act, perjury in the second degree pursuant to Ala. Code 13A-10-102.NoI declare that upon enrollment I will be an alien lawfully present in the United States. I understand that Alabama law provides that any person who knowingly makes afalse, fictitious, or fraudulent statement or representation regarding lawful presence in the United States shall be guilty of a criminal act, perjury in the second degreepursuant in Ala. Code13A-10-102. Yes(If yes, please contact the Office of International Admissions.)NoHave you ever been found responsible for a disciplinary violation, academic or behavioral, in high school?YesHave you ever been convicted of or plead guilty to a felony or misdemeanor crime or are there any criminal charges pending against you?No3
PASSAGE USA APPLICATION PACKETI certify thatthe above information is trueand complete; I understand thatwithholding information requested, withthe exception of information designated asoptional, or giving false information may make me ineligible for admission and enrollment. I also certify that, if I am a male born on or after January 1, 1960, Icomply withthe provisions of the United States Military Selective Service Board or that I am not yet 18 years of age and I will register when required or that I amnot required by lawto register (this certification is required by State of Alabama Legislature Act 91-584). Although it is my responsibilitytoprovide officialdocuments, I grant the University ofSouth Alabama permission to request transcripts fromallschools thatI have attended.Signature of ApplicantSignature of Parent/GuardianDateDate*Your Social Security Number is optional as an applicant to the University of South Alabama and is usedfor identification purposes to match and process yourapplicationwith supporting documents.**Information relating to your ethnic background is requested for reporting requirements to the Department of Education. The data requested will be used only for therequired reports to this agency and will not be used in any way in the admission process.***Provision of this information is not mandatory and will not be used in any way in the admission process. Information on religious affiliation will be reported to localchurches. Its use is in the storage, retrieval, and reporting of information. Failure to provide this information will in no way affect your admission.The University of South Alabama does not discriminate in its student and employment practices in violation of any applicable laws.The University of South Alabama is an Equal Opportunity Employer - Minorities/Females/Veterans/Disabled.4
PASSAGE USA APPLICATION PACKETPASSAGE USA Application ChecklistPlease use this checklist for your own benefit. Make sure that all steps ofthe application process are complete and submitted to PASSAGE USAApplication has been extended after priority deadline: November 1.Until all slots are filled1. USA Application (make sure that all sections are complete)a.b.c.d.e.f.g.h.i.j.k.l.m.Identification InformationParent/ Guardian InformationHigh School InformationMiddle School InformationElementary encesDocument describing how PASSAGE USA will help you.Be sure to sign the application2. Signed Student Eligibility Form3. MedicalHistory4. Student & Parent/Guardian Memorandum of Understanding5. Reference form from teacher6. Copy of most recent IEP and/or transition IEP7. Completed PASSAGE USA Personal Support Inventory8. Copies of high school transcripts or final report cards from past 2 years, including attendancerecords.9. Proof of Intellectual Disability diagnosis (e.g., Notice & Eligibility Decision Regarding Special EducationServices)10. Check made payable to the University of South Alabama for the application fee ( 45)11. Mail the completed application, supporting documents, and application fee to:PASSAGE USA307 University Blvd. N.Department of Leadership and Teacher EducationUCOM 3100University of South AlabamaMobile, AL 366885
PASSAGE USA APPLICATION PACKETApplicant’s Name:Student Eligibility FormPlease initial in the appropriate boxes to confirm the student meetsthe eligibility criteria for PASSAGE USA.StudentInitial . Parent/GuardianInitial Requirement Between 18-25 years old.Not receiving special education and related servicesfrom the public schools.Diagnosed with an intellectual disability (ID), as definedby an IQ of 70 or below and low adaptive behavior.Uses functional communication, reading, and math skills.Functions independently without attendant care.No current, serious, or chronic history ofcriminal conviction.No current or chronic history of inflicting physical harmto self or others.No medical conditions that are communicable bycasual contact.Uses self-help skills and safely functions withoutdirect supervision.Motivated to continue education and furtherdevelop employment and independent living skills.Has a Smartphone and uses it for calls, texts, and email.By signing this form, I certify that I have read and understood the eligibility requirements forPASSAGE USA. I verify that all of the above that I have initialed are true to the best of myknowledge. I understand that these requirements are only the basic program requirementsand that the final acceptance to Passage USA is not based solely on the above responses.StudentSignatureDateStudent's emailParent/ Guardian SignatureParent's emailDate6
PASSAGE USA APPLICATION PACKETMedical History1. Briefly describe your medical history (include all disability diagnoses):2. Please list all medical, psychiatric, behavioral, and/or physical conditions that mayimpact your participation in classroom, social, or recreational activities (includingallergies):3. Please list any medications you are currently taking.a. I can take all of my medications independently, including knowing when and howmuch to take.* Please verify with initial:StudentParent/ Guardian7
PASSAGE USA APPLICATION PACKET4. Do you currently receive private/public/agency therapeutic services, such as PT, OT,psychiatry, speech, or behavioral therapy? If yes, list them here:Please provide any other medical information that you feel would be important regarding yourparticipation in PASSAGE USA.8
PASSAGE USA APPLICATION PACKETStudent & Parent/GuardianMemorandum of Understanding andRelease of LiabilityApplicant Name:PASSAGE USA at the University of South Alabama is a post-secondary educationprogram to help young adults, who have been diagnosed with an intellectual disability (ID),gain work skills and practice some independent living skills. Completing this application doesnot guarantee the student a spot in the program. Final acceptance to the program will bedecided after careful review of all applications, related documents, and student interviews byPASSAGE USA administration.PASSAGE USA is in an inclusive and integrative university setting. All PASSAGE USAstudents will be treated and viewed as university students. The following services will beprovided to all PASSAGE USA students: Person-centered planningAcademic advisingAcademic, social, and wellness mentoringCareer awareness and development of work-related skillsIndependent living skills developmentCampus inclusion & membershipSelf-determination development (increased)Because the goals of PASSAGE USA include allowing students to have a form of collegeexperience and gain independence, the following are NOT provided by PASSAGE USA: 24/7supervision Daily/weekly student progress reports to parents/guardians One-on-one supervision throughout the entire school day (including traveling to andfrom classes, during class, and during PASSAGE USA activities)PASSAGE USA is also NOT responsible for the following: Students’ personal belongingsStudents’ personal finances and money in possession of studentsStudents’ diet on campusStudent conductGuaranteeing paid employment either during or upon completion of PASSAGE USA9
PASSAGE USA APPLICATION PACKETPASSAGE USA will expect a high level of support from parents/guardians regarding thepurpose and goals of the program. As parent(s)/guardians, you need to clearly understand theexpectations and agree to the limitation of PASSAGE USA to provide direct teachercontact/supervision to the students enrolled. Some opportunities provided by PASSAGE USAmay occur apart from the time of traditional college classes (weekends & nights) and are notlimited to the students’ scheduled class times. Students are required to: Travel throughout campus independently Be responsible for arranging transportation to and from USA campus and otherPASSAGE USA activities’ locations Manage their own schedule for school, employment experiences, and socialactivities Own a Smartphone and know how to use it for texting, phone calls, and email Desire to participate in campus activities (both specifically PASSAGE USA activities &general USA community activities) Be responsible (or family must be responsible) for the costs of students’ mealsduring the semester Provide (or family must provide) their own school supplies (books, paper, pencils,pens )PASSAGE USA is committed to providing students who meet eligibility requirementswith an opportunity to have a post-secondary educational experience. It is PASSAGE USA’s goalto assist students in the development of skills needed to live independently (or somewhatindependently) and acquire skills needed for successful employment. PASSAGE USA will usePerson-centered planning and Adult Education Plans (AEPs) to set students’ goals anddetermine students’ course selection and job/internship experiences each semester. Pleaserealize that upon completion of PASSAGE USA students will receive a certificate not adiploma. Students will not receive any college credit for their participation in classes.I understand that if I/my student,, is accepted intoPASSAGE USA that the parent/guardian will provide the necessary materials and support. Ialso understand that students will not be supervised at all times by PASSAGE USAadministration. There are risks associated with any program provided on a university campusor in a community setting, and I, in full recognition and appreciation of any and all risks, hazards,and dangers inherent in participation in this program, am willing to accept those risks. Further, Ido for myself, my child or ward, our heirs and personal representatives, agree to holdharmless and indemnify, release and forever discharge PASSAGE USA, the University ofSouth Alabama, its trustees, officers, employees, volunteers and students from and against anyand all claims, demands and actions or causes of action on account of or resulting from mychild/ward’s participation in Passage USA. I further understand that the University of SouthAlabama, its trustees, officers, employees, volunteers and students assume and accept noliability for personal injury, loss of life or damage to personal property.Student Signature:Date:10
PASSAGE USA APPLICATION PACKETPrinted Student Name:Parent/GuardianSignature:Printed Parent/ Guardian Name:Date:11
PASSAGE USA APPLICATION PACKETPASSAGE USA Reference FormPlease give the attached documents to the teacher you designated as your referenceon the application. Your reference should be someone who has personally taught youand who knows you well. Please attach your completed reference form to theapplication packet to submit to PASSAGE USA.12
StudentName:PASSAGE USA APPLICATION PACKETPASSAGE USA Reference FormReference for(Please use full legal name)Reference ne number:Best time to call is:Weekday mornings (after 9am)Weekday afternoons (after12pm)Weekday evenings (after 4pm)Other (please write best time for you)Job titleHow long have you known the applicant?14
StudentName:PASSAGE USA APPLICATION PACKETApplicant Skills and Abilities:Please rate the applicant’s level of independence in the following areas with thefollowing scale: 3-student is independent, 2—student requires some/moderate support,1—student requires complete support, NA—not applicable to student/have notobserved.Level of zationalSkillsNavigateFamiliarTime Management SkillsBuilding/ MaintainingPeerAdult-Student RelationshipsDemonstrates Self-ControlSocial Skills (Greets,shakes hands, th3Student isindependent2Student needssome support1StudentneedscompletesupportNotapplicableto student15
StudentName:PASSAGE USA APPLICATION PACKETIs there anything else about the student that you would like to share or think that PASSAGEUSA should know?Teacher Signature:Date:Printed Name:Thank you for your time in completing this form!Please mail it to:PASSAGE USA307 University Blvd. N.Department of Leadership and Teacher EducationUCOM 3100Mobile, AL 3668816
PASSAGE USA APPLICATION PACKETPASSAGE USAPersonal Support InventoryTo be filled out by: parent/family/guardian/primary support person.Instructions: Please use the following scale to represent level of functioning in each section: (3) Student is independent (2) Student requires some/ moderate support (1) Student requires complete support (NA) Not applicable to studentWhen necessary, write notes to explain scaled responses.Eating and Food Preparation:Level of SupportPreparing meals and snacks:1. Gathers ingredients and equipment2. Opens containers3. Follows recipe4. Uses microwave5. Uses stovetop6. Uses oven7. Uses other appliancesEatingmeal/snack:8. Has appropriate oral motor skills (i.e.chewing/swallowing)9. Uses utensils10. Uses mannersPreparing eating area:11. Sets table12. Gets condimentsCleaning up after meal:13. Puts away leftovers14. Wipes off work surface15. Washes dishes by hand16. Washes dishes with dishwasherAccessibility to kitchen:17. Uses adaptive equipmentComments:3Student isindependent2Studentneeds leto student17
PASSAGE USA APPLICATION PACKETGrooming and Dressing:Level of Support3Student isindependent2Studentneeds leto student3Student isindependent2Studentneeds leto studentGrooming1. Brushes teeth2. Uses mouthwash3. Brushes/ combs hair4. Styles hair5. Takes care of skin6. Uses make-up7. Cleans eyeglasses8. Cleans hearing aid ear molds9. Maintains appearanceDressing / Undressing10. Dresses and undresses self11. Chooses appropriate clothes12. Dresses appropriately for season/weatherconditionsComments:Hygiene and Toileting:Level of Support1.2.3.4.5.6.7.Using private and public toiletsTakes care of toileting needsWashes handsPersonalHygieneBathes/ showersShampoos/ rinses hairManages menstrual careShavesUses deodorantComments:18
PASSAGE USA APPLICATION PACKETSexuality, Health, Safety:Level of SupportAwareness of sexuality issues1. Has awareness of public vs. private activities2. Closes door for bathing, toileting,dressing, etc.3.Shows affection appropriately4. Appropriately controls sexual needs5. Has awareness of bodily and sexual functions6. Has knowledge of use of birthcontrol methods7. Has knowledge of sexually transmittedKnowledge of general health concerns8. Disease transmission (i.e., covers mouthwhen sneezing/ coughing, controlsdrooling, blows nose, etc.)9. Has health concerns specific to disability(i.e., skin care, range of motion, positioningof weight)10. Manages medication (i.e., knowsmedication schedule, ability toswallow, related behavioral11. Cares for minor injury and/or illnessAwareness of home hazards andemergency procedures12. Uses adaptive strategies to avoidhd of danger associated13. Showstawarenesswith poisons14. Understands what to do in case of fire15. Understands what to do in caseof accidentsComments:3Student isindependent2Studentneeds letostudent19
PASSAGE USA APPLICATION PACKETTravel:Level of Support“Walking” (Wheeling) to and from Destination1. Is aware of safety procedures whencrossingstreets2. Arrives at destinationRiding Bicycle3. Knows safety rules4. Is able to find way5. Locks bicycleRiding School/City Bus6. Demonstrates appropriate behaviorwhen on the bus7. Communicates with bus driver8. Can find appropriate bus9. Can read bus map10. Can make a transfer11. Knows how to pay12. Shows bus passOrientingSkills13. Identifies signs14. Carries identification15. Asks for help16. Is responsible for possessions17. Uses caution with strangers18. Reads mapsComments:3Student isindependent2Studentneeds leto student20
PASSAGE USA APPLICATION PACKETUses Services:Level of Support3Student isindependent2Studentneeds somesupport1.2.3.4.Uses Relay system (if hearing impaired)Makes appointmentsUses banking servicesUses/ communicates with dentist,doctor, etc.5. Uses laundry/ eto studentComments:General ShoppingLevel of SupportHandling Money/ Budgeting1. Makes shopping lists2. Stays within budget3. Handles money exchangesLocating/ Getting Items4. Pushes cart5. Uses store directory6. Asks for help7. Follows list8. Makes appropriate choices9. Does cost comparisons10. Selects appropriate store11. Asks for help12. Selects items within budget13. Knows sizes14. Makes wise choicesRestaurant15. “Reads” menu (or alternative)16. Communicates with waitperson17. Uses manners18. Locates restrooms19. Pays bill (including tip)3Student isindependent2Studentneeds leto student21
PASSAGE USA APPLICATION PACKETComments:Household and maintenance:Level of Support1.2.3.4.5.6.7.3Student isindependent2Studentneeds somesupportKeeping room neatMakes bedChanges bed linensStraightens roomHandling of household choresDoes laundryVacuums/ dustsCleans cableto studentComments:Social Skills:Level of SupportTelephone Use1. Uses phone etiquette2. Takes message3. Dials phone4. Can use phone for emergency5. Can use phone directory6. Sends a text message7. Receives a text messageCaring for Others8. Takes care of pets9. Takes care of sibling(s)10. Babysits11. Cares for elderly12. Gives gifts13. Remembers birthdays14. Sends thank you card/note3Student isindependent2Studentneeds leto student22
PASSAGE USA APPLICATION PACKETSocial Skills:Level of Support3Student isindependent2Studentneeds leto student15. Introduces self16. Follows instructions17. Accepts criticism or consequence18. Accepts no for an answer19. Greets people20. Gets people’s attention appropriately21. Makes requests appropriately22. Disagrees appropriately23. Gives negative feedback appropriately24. Resists peer pressure25. Apologizes26. Engages in conversation27. Gives compliments28. Volunteers to help29. Reports peer behavior appropriatelyComments:Planning/Scheduling:Level of SupportFollowing Daily Routines1. Shows up on time2. Gets to where they are supposed to be3. Adapts to changes in routine4. Is able to tell timeScheduling WeeklyActivities5. Uses a time management system(i.e., calendar/daytimer)6. Maps out plans and time (i.e.,organizes time)3Student completesupportNotapplicableto student23
PASSAGE USA APPLICATION PACKETPlanning and Scheduling:Level of SupportPreparing for Special Outings7. Arranges special things to do8. Handles logistics involved in planningan eventHandling Time Management9. Plans homework time10. Arranges study area11. Attends to homework12. Plans time for chores, meetings,leisure time13. Arranges transportationComments:3Student isindependent2Studentneeds leto student24
PASSAGE USA APPLICATION PACKETPASSAGE USA Certificate Program FeesStudents admitted to the PASSAGE USA Certificate Program will register for specialized and inclusivecourses each semester. These courses will be taken for credit toward the PASSAGE USA certificate. Thecourses will not be taken for degree credit. Two of the courses will include PASSAGE USA students only.The other courses will be selected from USA’s traditional course offerings and will include students fromthe University community. There is a flat fee for the program. Information about the program fee isavailable at: pusa admissions.htmlAdditional Fees: for new studentsApplication fee: 45ID fee (for those enrolling): 10Orientation fee (for those enrolling): 100The University reserves the right to change fees, as approved by the USA Board of Trustees,without prior notice.Questions?Contact PASSAGE USA at 251-460-7558 or passageusa@southalabama.edu25
University ofSouth Alabama Department LeadershipandTeacherEducation 307. University Blvd., N Mobile, AL36688-0002 University of South Alabama Application for PASSAGE USA Phone:(251) 460-7558 Fax:(251) 380-2758 Email:passageusa@ southalabama.edu Please PRINT orTYPE alloftheinformation requested. LEGAL NAME: Last
