Tuesday, April 11, 2017

Form to use to refer a student(s) for Pre-Employment Transition Services through Vocational Rehabilitation

Please submit completed form to the Special Education Director for your School District. For more information, contact Chris Bean at the Maine Division of Vocational Rehabilitation: Christopher.B.Bean@maine.gov

Maine Division of Vocational Rehabilitation
Request for Pre-Employment Transition Services 

Student Name:      
Gender:Choose an item.
Date of Birth      
SSN: (optional)     



Mailing Address:     
City:     
State: ME
ZIP Code:     



Phone:      

Email:      

School:     

Current Grade:      
Anticipated graduation year:     

☐Currently receives special education services
☐ Currently has a 504 plan
☐ Does not receive services
☐ Not sure

By signing this form, I am requesting Pre-Employment Transition Services from the Maine Division of Vocational Rehabilitation (DVR) based upon the criteria that I am a student who is potentially eligible for DVR services. I understand that in order to pursue DVR services other than Pre-Employment Transition Services, I will need to complete an application and provide DVR with information needed to determine my eligibility.    
Student Signature:     
Date:     

Representatives name/signature:     
Date:     
(If participant is under 18 a parent or guardian signature is required)

     
By signing below, I indicate that I understand that the information I have provided above may be
released to
     
(school) for the purpose of promoting access to
Pre-Employment Transition Services. I also agree that the school may provide VR with my IEP - or provide verbal or written confirmation - that demonstrates that I am a student with a disability. This information will be kept for one year and can be revoked, upon written request, at any time. This information may also be used for data collection and reporting purposes.

Student Signature:     
Date:     

Representatives name/signature:     
Date:     
(If participant is under 18 a parent or guardian signature is required)

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