EDUCATE Application

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Download a PDF version of this form

Personal Information

Name*

First Last

Phone*

Email*

Address*

Street Address City State ZIP Code

Birthdate*

Month

Day

Year

Secondary Contact (Name)

First Last

Relationship

To give 51�� permission to contact this individual on your behalf, please see the Authorization for Release of Confidential Information form

Checklist for consideration of admission to the program

Please read through this list and check all that apply*

I have a documented diagnosis of Intellectual Disability.

I am between the ages of 18 and 25.

I’ve been exited from high school/secondary education (e.g have an IEP diploma, Certificate of Attendance or other high school completion document).

I have a goal and the necessary documentation (e.g., social security card, green card) for gainful employment.

I have functional reading and writing skills that allow me to solve problems and complete daily activities.

I have the ability to transport myself or arrange transportation to and from campus (or from 51�� Student housing to campus).

I am able to navigate the 51�� campus environment independently, or with a self-provided personal attendant.

I have the basic safety skills to participate in an unsupervised setting.

Education Information

Education completed*

HSED

High School Diploma

Certificate of Completion

Other

Name of School Attended*

Year credential was earned*

Are you currently part of an Adult Transition Program?*

Yes

If yes, when do you plan to graduate or transition out of the program?*

Educational Goals

Check any of these educational goals that apply*

Academic Skill Development: Enhance basic academic skills in reading, writing, and mathematics to a level necessary for success in a postsecondary setting.

Career Exploration: Aim to explore various career paths and the corresponding academic requirements, to make informed decisions about future class selections and professional goals.

Learning Strategies: Focus on acquiring and refining learning strategies tailored to individual needs, such as note-taking techniques, test-taking strategies, and effective use of technology for learning.

Social Skills Development: Improving social interactions, understanding social cues, and developing friendships.

Independent Living Skills: Learning to manage finances, time management, and public transportation.

Self-Advocacy and Self-Determination: Learning to advocate for self in both educational and personal contexts.

Technology Proficiency: Gaining or improving computer and technology skills necessary for both academic success and everyday living.

Community Involvement: Aiming to become more involved in the community through volunteer work, extracurricular activities, or community service projects.

Physical Health and Wellness: Developing a fitness routine or learning about nutrition and health to improve physical well-being.

Other

Please list other educational goals*

Work Experience

Do you have prior work experience?*

Yes

Employer*

Was this a paid or volunteer position?*

Paid

Volunteer

Position*

Employer Address*

Street Address City State ZIP Code

Duties Performed*

Starting Date*

Month

Day

Year

Are you still working for this employer*

Yes

Ending Date*

Month

Day

Year

Beginning Wage*

Ending Wage*

Immediate supervisor’s name*

Supervisor's phone number*

How many hours did you work a week?*

How did you find this job?*

Why did you leave this job?*

Did you have a job coach?*

Yes

Agency Name*

Did you use any supports during your employment, and if so, what were they?

Vocational Interests

What kind of job would you like to have?*

What skills do you have that would help you be successful in the above job?*

Workplace Accommodations

What workplace accommodations have you received in the past during your previous employment, if applicable?

What workplace accommodations do you anticipate you may need based on your vocational interests?

Support System

Does your family/support system support you in your desire to take classes at 51��? (Please explain)

Does your family/support system support you in your desire to get a job? (Please explain)

Transportation Information

How do you plan to get to and from the 51�� campus and to off-campus work experiences?*

I plan to live in 51��’s Campus View Housing Complex

Other

Safety

Do you have any concerns for your safety while participating in the EDUCATE Program?

Verification of Disability

Documents that should be emailed or sent to the 51�� EDUCATE Program:

Verification of your diagnosis of intellectual disability.
An AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION for any individual you would like to give us permission to speak with on your behalf.
1. The form is provided as a downloadable, fillable pdf but you may also request a hard copy of this document be sent to you by emailing EDUCATE@niacc.edu. Please specify how many copies you require (based on the number of individuals/agencies that you will want 51�� to exchange of information with on your behalf.

Email these documents to EDUCATE@niacc.edu or mail them to 51��, EDUCATE Program, 500 College Drive, Mason City, IA 50401.

Note: Verification of your diagnosis of intellectual disability is necessary before admission to the program can be considered.

Application Agreement*

I hereby certify that all the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations may result in the denial of my application or termination of engagement if discovered at a later date. I agree to notify 51�� immediately of any changes to the information provided.

51����

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