Pre-ETS Student Enrollment Form

PRE-ETS STUDENT ENROLLMENT FORM

The Pre-Employment Transition Services (Pre-ETS) program provides work-readiness and transition supports to eligible secondary and postsecondary students with disabilities. Enrollment in this program requires provision of identifying information, confirmation of disability status or referral source, consent to release records where applicable, and acknowledgment of program policies. Completion of this form enrolls the student in Pre-ETS activities as indicated below and authorizes the program provider to coordinate services described herein.

Student Information

Date of Birth:    Student ID / School ID:

Parent / Guardian (If Student is a Minor)

Student is under 18 years of age:

Eligibility and Referral

Disability status / documentation (check all that apply):

IEP    504 Plan    Documented disability (medical/psychological record)    Unknown / Referral pending

Requested Pre-ETS Services

Please select the services you/your student wish to enroll in (check all that apply):

Job exploration counseling    Work-based learning experiences    Counseling on postsecondary education    Workplace readiness training    Instruction in self-advocacy

Accommodations, Transportation, Medical and Emergency

Authorization to Access Records & Confidentiality

By signing below, I authorize the release of educational, medical, and vocational records relevant to program participation between the student's school, medical providers (if necessary), and the Pre-ETS program provider for the purpose of determining eligibility, developing an individualized plan, and reporting outcomes. I understand that information shared will be treated as confidential in accordance with applicable law and program policy, and will be used for administrative and reporting purposes.

Consent to release records to Pre-ETS provider:    Consent to discuss program participation with school staff/referral source:

Program Policies, Liability and Data Use

Participation Expectations: Students must attend scheduled activities, notify program staff of absences in advance when possible, and follow program rules. Failure to comply with conduct or attendance standards may result in suspension or termination from program activities.

Liability: The program will take reasonable steps to provide a safe environment. By signing, I acknowledge that the program is not liable for incidents that occur as a result of failure to disclose medical or behavioral conditions that would reasonably foreseeably increase risk. I agree to inform program staff of conditions that may affect safety or participation.

Data Use: Information collected through this form and participation records may be used for program evaluation and reporting. Personal identifiers will be handled consistent with confidentiality obligations; aggregated or de-identified data may be used for reporting performance and outcomes.

Cost: Pre-ETS services are provided at no direct cost to the participant unless a specific fee for an optional service is stated in a separate written agreement. When specialized supports are required, the program will notify the parent/guardian or participant and obtain agreement for any costs or third-party arrangements.

Media and Photo Release (Optional)

I grant permission for the program to take photographs or video recordings of the participant for program documentation, publicity, or reporting purposes. I understand that I may revoke this consent at any time by providing written notice to the program provider; revocation will not apply to media already used.

Photo/video consent: Yes    No

Acknowledgment and Signature

By signing below I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand the nature and scope of the Pre-ETS program and authorize the use and/or release of records as indicated. I acknowledge that I have read and accept the program policies, liability statements, and data use terms set forth above.

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