Vocational Evaluation Application

"*" indicates required fields

Participant Contact Information

Name*
Street Address*
Birth Date*

Supports Coordinator

Coordinator Name*

Availability

During which days and hours are you available to work? (Hours are 9 AM to 3 PM).
Weekday Mornings*
Weekday Afternoons*

Family or Support Person Contact Information

Family/Support Person Name*
Family/Support Person Street Address*
Are you filling out the application for this participant?*
Do you wish to receive all follow-up messages from our Vocational Evaluator?*

Person to Notify in Case of Emergency

Emergency Contact Name*
Emergency Contact Street Address*

Agreement and Signature

Once this application is submitted it will be reviewed by our Vocational Evaluator. Follow up instructions and next steps will be provided by email. Please keep in mind that all applicants must submit their ISP or IEP and an OVR (Office of Vocational Rehabilitation) case closure letter. Participants 24 years of age or younger must also provide: OVR case closure letter, career counseling letter, and transition counseling letter. By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted to this program, any false statements, omissions, or other misrepresentations made on this application may result in immediate dismissal.

Our Policy

This organization's policy is to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

Thank you for completing this application form and for your interest in our program.

HC Opportunity Center
P.O. Box 72646
215 Barley Sheaf Road
Thorndale, PA 19372
Phone: 610-384-6990 x215

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