Successful Transitions

Application for Services

To apply for services with Successful Transitions, please complete the form below.

Student's Name

Date of Birth

Last 4 Digits of Social Security #

Gender

Race

Street Address

City

Zip

County of Residence

Student's Phone #

Student's Email

Name of School

Parent's Name

Parent's Phone #

Parent's Email

Homeroom/Resource Teacher

504 - IEP - State which plan

Diagnosis / Disability

Media Release: Please check below if you give permission for the CareerBOOST team to use pictures/media samples of your child for videos, advertising and educational purposes.

I agree
I disagree

RELEASE OF INFORMATION:

By signing this application, I hereby state that all information I have given is true. I also give permission for SUCCESSFUL TRANSITIONS to actively access information to better serve my child. All information kept in his/her file, is the property of the student and the school he/she attends. The SUCCESSFUL TRANSITIONS team understands the importance of privacy*, and all personal, financial, disclosure-related, and IEP/504 information will not be shared with any third parties except for South Carolina Commission for the Blind.

I further grant permission for my child to meet with SUCCESSFUL TRANSITIONS during school hours when appropriate.

I understand that, I/my child must meet the criteria to receive SUCCESSFUL TRANSITIONS services and will not receive or be eligible for a certificate of completion unless the post-test provided is passed with a grade of 70 points or higher.

E-Signature of Parent or Guardian (if student is younger than 18)

Date of Parent or Guardian Signature

E-Signature of Student

Date of Student Signature

*CareerBoost and Successful Transitions view all materials pertaining to a student's disability as confidential. This policy is based upon government mandates regarding the confidential treatment of disability-related information. Personal and Disability information may be released only when a student has signed a Release of Information form. A student may request to review the contents of his/her own file when the CareerBOOST Director or assigned Transitions Consultant is present.

PERMISSION AND TRANSPORTATION AGREEMENT

Student's Name

Please check the following permissions and agreements:

As the parent/guardian of the child listed above, I give permission for my child to participate in Successful Transitions activities.I hereby release NFBSC Successful Transitions, its employees, agents, and volunteers, from all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage, or inquiry (including death) that may be sustained by my child while participating in or traveling to and from events.As the parent/guardian of the child listed above, I give my permission for my child to participate in Successful Transitions activities.I understand that my child may or may not attend events that are not organized by the school listed above and agree to hold the school and school district harmless of any liability while participating in and traveling to and from events.I agree to accept full responsibility, financially or otherwise, for any damage my child may cause to the properties visited on outings, other’s personal property, or vehicles used for transportation.

I agree and consent to all the above statements:

I agreeI disagree

E-Signature of Parent/Guardian/Student if over 18 years of age

Date

Apply

Application for Services