Transitions All Year

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Fields

Transition All Year Registration

Participant Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Cell Phone Number

Home Phone Number

Birthdate

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Month

Day

Year

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

Legal Guardian Name

First Name

Last Name

Name of person completing this form

First Name

Last Name

Relationship to participant

What grade is participant currently in?

Do/did you have any accommodations?

Yes No

Accommodations provided:

Are/were you in a life skills program?

Yes No

What type of training?

Any vocational experience?

Yes No

What type of training?

Have you worked with JFS in the past?

Yes No

In what capacity?

How were you referred to JFS?

Disability Questions

Do you have a disability?

Yes No

Does this disability impact your ability to look for or maintain a job?

Yes No

Please provide additional information:

Are you deaf or have serious difficulty hearing even with a hearing aid?

Yes No

Are you blind or have serious difficulty seeing even with corrective lenses?

Yes No

Do you have difficulty walking?

Yes No

Do you have difficulty with your daily activities such as bathing or dressing alone?

Yes No

Do you have difficulty concentrating or focusing on details?

Yes No

Do you have difficulty in making decisions?

Yes No

Do you have difficulty visiting a doctor alone or running errands?

Yes No

Do you have a physical, mental or emotional condition that impairs your ability to find or maintain employment?

Yes No

Are you a past or current client at the Department of Assistive and Rehabilitative Services?

Yes No

Please provide your counselor's name:

First Name

Last Name

Please provide your counselor's phone number:

Do you have any vocational goals/desires that you can share with us?

Are there any jobs/places of employment that you would prefer to stay away from?

List any other issues that you would consider a barrier to finding or maintaining employment.

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Download packet from website: www.jfshouston.org/forms/transitions-all-year

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