Application for Spectrum Innovates Pathway Program

Application for Spectrum Innovates Pathway Program
SPECTRUM INNOVATES PATHWAY PROGRAM (SIPP) APPLICATION FOR YEAR BEGINNING JULY 2022
Please complete all items on this application. Your answers will help us to determine your suitability for the program. You may attach additional pages if needed.
GENERAL INFORMATION
Name of applicant
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preferred pronouns
Country
Home phone (with area code)
Cell phone (with area code)
Email address
example@example.com
Date of Birth

Month Day Year
Date
Date of completion of high school requirements

Month Day Year
Date
Is the applicant a U.S. citizen?

Is the applicant a U.S. citizen? Yes Is the applicant a U.S. citizen? No I-20 Immigration form needed? Yes I-20 Immigration form needed ? No
If not a U.S. citizen, does the applicant hold permanent resident status?

Yes No
What is the applicant's country of citizenship?
What is the applicant's native language?
Other languages spoken
Does the applicant hold a driver's license?

Yes No
State license was issued

Month Day Year
Date
How did you hear about SIPP?

Website Referred by teacher/guidance counselor Friend in program Social media College fair (please specify) Other (please specify)
FAMILY INFORMATION
Applicant lives with

Other (specify relationship) Mother Self Father
Parent / Guardian 1
Name
Address

Address

Street Address Line 2

City State

Zip code
Occupation
Cell phone (with area code)
Cell phone (with area code)
Business phone
Fax
Email
example@example.com
Parent / Guardian 2
Name
Address

Address

Street Address Line 2

City State

Zip code
Occupation
Home phone
Cell phone (with area code)
Business phone
Fax
Email
example@example.com
Parent / Guardian 3
Name
Address

Address

Street Address Line 2

City State

Zip code
Occupation
Home phone
Cell phone (with area code)
Business phone
Fax
Email
example@example.com
Person responsible for tuition
Name
Person responsible for tuition
Relationship
Parent with whom applicant resides permanently (if applicable)
Name
Relationship
Does the parent of the applicant have legal guardianship or power of attorney?

Yes No
If yes, please provide copy of documentation
List the applicant's high schools and colleges and dates of attendance. Also include other educational experiences, such as summer programs and enrichment and dates of attendance.
If diploma or certificate awarded, type and date received
Applicant's area of career interest
Upon acceptance to Spectrum Innovates Pathway Program and prior to admission an applicant is required to submit a completed medical history form
Please check all applicable

Hearing Impaired Visually impaired ASD Emotional difficulty Oppositional Defiant Disorder Intellectual disability Multiple disabilities Orthopedic impairment Other health impairment Learning disability (specify) Speech/language impairment Traumatic brain injury ADHD type
Please check all applicable

Other be as specific as possible
Other (be as specific as possible)
Spectrum Innovates Pathway Program requires two written recommendations. These should come from individuals outside the family. Teachers, guidance counselors, and former employers are suggested sources for recommendations.
Name
Recommendations will be sent from
Title/position
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work phone
Name
Work phone
Name
Name
Recommendations will be sent from
Title/position
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address

Address

Street Address Line 2

City

Zip code
My signature below indicates that all the information in this application is true and complete.
Signature of applicant

Clear
Date

Month Day Year
Date
Signature of preparer

Clear
Date

Month Day Year
Date
Please note: Spectrum Innovates Pathway Program (SIPP) is a Comprehensive Transition Post-Secondary Program. For the last six weeks of the program applicants must be able to live in a residence hall environment with supervision comparable to a typical college residential setting. SIPP is not aresidential treatment center, group home, or psychiatric facility. If it is later determined that a student was admitted to SIPP on the basis of incomplete or misrepresented information provided during the admission process, the student will be dismissed from the program. In either case, the deposit will not be refunded.Spectrum Innovates Pathway Program operates as an educational partner with Vaughn College and adheres to its Drop/ Add policies, annual insurance policies, tuition policies, insurance policies, and related refund practices.

PLEASE UPLOAD A VIDEO TO (3 min. maximum):

Why would you like to be a student in SIPP @ Vaughn?

How do you think SIPP can help you attain your future goals?
SIPP APPLICATION CHECKLIST

Have a documented diagnosis of ASD and provide certified test results Be at least 18 years of age when you enter SIPP; upper limit is 23, with some flexibility Submit completed and signed application Provide copy of Legal Guardianship paperwork if applicable Provide official school transcript(s) confirming completion of your state's high school requirements Provide copy of recent psych-ed evaluation (preferably no more than 3 years old) including IEP and any diagnosis of learning Visit Vaughn College campus for a tour and in-person interview Schedule and complete admission assessment (may be online or in person) Submit a video 3 minutes max describing desire to be a SIPP @ Vaughn student Provide 2 letters of personal recommendation from professional sources (teacher, guidance counselor, employer, principal, psychotherapist or therapist)
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Application for Spectrum Innovates Pathway Program

SPECTRUM INNOVATES PATHWAY PROGRAM (SIPP) APPLICATION FOR YEAR BEGINNING JULY 2022

GENERAL INFORMATION

FAMILY INFORMATION