HANDSmade Application

Applicant Information

1. HANDSMade Client Name: *This question is required.

2. Client Date of Birth: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

3. Client Gender

4. Client Race

5. Client Address: *This question is required.

6. Client E-mail: This question requires a valid email address.

7. Client Phone Number:

Additional Contact Person:

8. Name of Contact Person: *This question is required.

9. Relationship to the Applicant: *This question is required.

10. Contact E-mail: *This question is required. This question requires a valid email address.

11. Contact Phone Number: *This question is required.

Education & Experience:

12. Client Education:

High School (list name)
College (list name)
Other trainings, certifications

Diploma Earned? (Yes/No)
Degree Earned? (Yes/No, and list major)

13. Client Employment/Volunteer Experience:

Space Cell	Employer	Position	Date Started	Date Ended	Duties	Reasons for leaving
1	Employer	Position	Date Started	Date Ended	Duties	Reasons for leaving
2	Employer	Position	Date Started	Date Ended	Duties	Reasons for leaving
3	Employer	Position	Date Started	Date Ended	Duties	Reasons for leaving
4	Employer	Position	Date Started	Date Ended	Duties	Reasons for leaving
5	Employer	Position	Date Started	Date Ended	Duties	Reasons for leaving

14. Client Present Academic Level

15. Client Present Functional Level

16. Client Present Vocational Level

17. Client Present Behavioral Level

Interests and Skills:

18. What are your work interests? (check all that apply)

Work on a computer
Create things (e.g., arts/crafts)
Organize things
Work with people (example: a greeter)
Other Please enter an 'other' value for this selection.

19. Can you use/do the following? (check all that apply)

20. When working on a computer, what can you do?

Add pictures (list programs, for example: MS Word)
Create tables (MS Word)
Create charts (MS Excel)
Type text (list programs, for example: MS Word) Please enter an 'other' value for this selection.
Modify text (list programs, for example: MS Word) Please enter an 'other' value for this selection.
Adjust pictures (list programs, for example: MS Word) Please enter an 'other' value for this selection.
Modify font, size, and style (list programs, for example: MS Word) Please enter an 'other' value for this selection.
Enter data (ex: MS Excel) Please enter an 'other' value for this selection.
Other Please enter an 'other' value for this selection.

21. Are you: (check all that apply)

Independent
Good with working in groups
Creative
Friendly

Helpful
Outgoing
Good at explaining things to others
Energetic

Accurate
Organized
Other Please enter an 'other' value for this selection.

22. List your areas for improvement (for example, working in a team/group):

23. Sample areas for which transition goals focused on within secondary settings:

Independent living:
Community participation:
Education & training:

24. What are some of the current goals or areas where growth or support is needed to reach your individual transition goals as they pertain to employment, education and training, community participation, and independent living?

25. Why would you like to work at HANDS as part of the HANDSmade program?

HANDSmade Application

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