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Project LIFE - Marshfield [Preliminary Application]

Required

Note:
If you are unable to complete this form online, please download and complete the PDF form below. Once completed, you can submit the form via email or mail as instructed in the attachment.
 

Project LIFE Application Form 

 

 

| Applicant Information

Please have the student fill out the information below

Applicant’s Namerequired
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Date of Birth (Must contain a date in MM/DD/YYYY format)
example@marshfieldschools.org
example@marshfieldschools.org
Street Address City, State, Zip Code
Must contain a date in MM/DD/YYYY format
DO YOU or WILL YOU have a court appointed legal guardian?:

 

| Funding Information

Do you work with the following agencies? 

(Not required to start Project LIFE)

DVR
Vocational Provider
SSI
ADRC
Long-Term Support
Student is currently participating in community-based vocational instruction
If yes, please list details
  • Business
  • Schedule
  • Hours per week
  • Duties
Business/Schedule/Hours per week/Duties
Business/Schedule/Hours per week/Duties

 

| Attendance

List Missed Days

 

| Work Skills

Review the skills below and rate yourself by selecting one of the listed options.

Select from the following options:

  • Never
  • Beginner
  • Intermediate
  • Advanced
Use Cell Phone or Technology DeviceSelect one
Select one
Computer (Word, Excel, Data Entry)Select one
Select one
Send/Receive EmailSelect one
Select one
Mailings (Label, Collate, Insert, Delivery)Select one
Select one
Alphabetize (ABC) Select one
Select one
Alphabetize (Numbers #)Select one
Select one
Utilizes organizational skillsSelect one
Select one
Counting (1-10)Select one
Select one
Counting (1-50)Select one
Select one
Counting by 5'sSelect one
Select one
Counting by 10'sSelect one
Select one
Recognize Expiration DatesSelect one
Select one
Simple Addition/Subtraction (with Calculator)Select one
Select one
Use a Calendar___ personal planner ___Select one
Select one
Read or use a checklistSelect one
Select one
Manage Time, Transition at Break/LunchSelect one
Select one
Telling time - Digital or AnalogSelect one
Select one
Follow a Schedule of Tasks/DutiesSelect one
Select one

 

| Level of Support

Please review the area and indicate whether you are able to work independently or if you require support.  

If you require assistance, please explain

Area: Social Skills
Area: Personal Care
Area: Mobility
Area: Problem Solving
Describe what assistance you need in this area
Describe what assistance you need in this area
Describe what assistance you need in this area
Describe what assistance you need in this area
Describe Behaviors

 

| Living Skills

Please review the living skill and indicate whether you are able to do it independently or if you require support.  

If you require assistance, please explain

Living Skill: Hygiene/Personal Care
Living Skill: Mobility
Living Skill: Telling time
Living Skill: Navigate within building
Describe what assistance you need in this area
Describe what assistance you need in this area
Describe what assistance you need in this area
If yes,Select all that apply
Select all that apply
Describe what assistance you need in this area

 

| Communication and Learning

Please provide information on abilities and styles

Preferred Form of CommunicationPlease select the one you use most often
Please select the one you use most often
Assistive Devices
Describe learning style
List your strengths, what are you good at?
Who will help you?

 

| Final Information

Do you want to apply for Project LIFE
0 / 3000
Must contain a date in MM/DD/YYYY format
Must contain a date in MM/DD/YYYY format
Terms of Service
Agreement

Application deadline is February 1st.

For more information about Project LIFE – Marshfield, please contact:

Nicole Larson, Project LIFE Instructor/Coordinator

1401 E Becker Rd.,
Marshfield, WI 54449

715-387-8464, ext. 4017
larsonn@marshfieldschools.org