BDI's Elevate AcademyAdmissions Application

This is a comprehensive application. Please ensure that all supporting documentation is ready to upload before starting. You may need up to 30 minutes or more to complete the application. Thank you for your time and effort!

Identity Documentations. At least one of the following:

State Issued ID/Driver's License
Birth Certificate
Social Security Card
Other verification of identity

Disability Documents. At least one of the following:

Psychological Evaluation
School IEP
Social Security Disability Determination/Award Letter
Medical Verification
Medicaid Award Letter
GVRA Authorization Form
GVRA Eligibility Determination Form
DBHDD I&E Assessment
VA Authorization for Services

Education Documents. At least one of the following:

Certificate of High School Completion
High School Diploma
General Education Diploma (GED)
Some college courses
Vocational training
Associate's Degree
Bachelor's Degree
Transcript

CONFIDENTIALITY STATEMENT

Confidentiality Statement and HIPAA Compliance Consent*

It is the policy of BDI to ensure the confidentiality of the individuals we serve in compliance with HIPAA and other federal and state laws regarding confidentiality. Any information entered on this application may not be shared with another person or agency without your prior knowledge and written consent.

Please type your full name below.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

Demographic Information

Who is completing this application*

Self (Potential Intern)

Legal Guardian

Applicant's Full Name:*

First Name, Middle Initial, Last Name (ex. John A. Doe)

Please list the name that you prefer to go by:

Date of Birth:*

Gender:*

Male

Female

Other

If you selected other, please list the gender you identify as below:

Please select your race below: (Select all that apply)*

American Indian or Alaska Native (e.g., Navajo Nation, Blackfeet Tribe, Inupiat Traditional Gov't., etc.)

Asian or Asian American (e.g., Chinese, Japanese, Filipino, Korean, South Asian, Vietnamese, etc.)

Black or African American (e.g., Jamaican, Nigerian, Haitian, Ethiopian, etc.)

Hispanic or Latino/a (e.g., Puerto Rican, Mexican, Cuban, Salvadoran, Colombian, etc.)

Middle Eastern or North African (e.g., Lebanese, Iranian, Egyptian, Moroccan, Israeli, Palestinian, etc.)

Native Hawai`ian or Pacific Islander (e.g., Samoan, Guamanian, Chamorro, Tongan, etc.)

White or European (e.g., German, Irish, English, Italian, Polish, French, etc.)

My race or ethnicity is best described as: (Feel free to use the text box and/or you can simply select categories above.)

My race or ethnicity is best described as: (Feel free to use the text box below and/or you can simply select categories above.)

Ethnicity/Hispanic Origin:*

Yes

No

Do you need an interpreter?*

YES

NO

Are you currently or have you ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard?*

Not a Veteran

Veteran

Disabled Veteran

Unknown

Verification of Lawful Presence:*

Verification of lawful presence in United States is required for adults seeking services paid for by community providers of services. In accordance with Georgia law, all programs and services receiving funding from state, federal or local funds are required to verify that adults who receive mental health, addictive diseases, and/or developmental disabilities services other than Emergency Services are lawfully present in the United States.

United States Citizen

Qualified Alien/Non-Immigrant

Non-Citizen/Qualified Alien under 18 years of age

Non-Citizen/Qualified Alien over 18 years of age

Disability Information

If applicable, please list any accommodations that you have or need:

Contact and Address Information

Address:*

City:*

State:*

GA

ZIP Code:*

Please select your county of residence below. Please write in county if not listed.*

Select or enter value

Primary Phone Number:*

Phone

Alternate Phone Number:

Phone

Applicant's Email Address:*

How do you prefer us to contact you?*

Primary Phone

Alternative Phone

Email

US Postal Services Mail

Do you authorize BDI to communicate with you via email?*

Yes

No

How many people are living in the applicant's home?*

What the applicants total household income?*

If individual is an adult under a guardianship, please include the total household income.

Select or enter value

Parent or Legal Guardian Information, if applicable

Do you have a Legal Guardian?*

If no, please skip to the Education and Work History Section.

If yes, please complete the information below.

Yes (Please upload Letter of Guardianship)

No

Legal Guardian Name

Legal Guardian Phone #

Phone

Legal Guardian Email

Do you authorize BDI to communicate with you via email?

Yes

No

Emergency Contact Information

Emergency Contact Name: *

Emergency Contact Phone Number:*

Phone

Emergency Contact Email Address:

Education and Work History

Do you have documentation of your education (diploma/transcript) that you can provide.*

Yes

No

Currently Attending High School?*

Yes

No

If currently attending High School. What is your anticipated graduation date?

Are you legally able to work in U.S.?*

Yes

No

Are you currently employed or have you been previously been employed?*

Yes

No

If yes, where do you or have you previously worked?

Use the space below to list any volunteer work, any work experience completed at school or in the community, non-paid training, and paid work you have had.

Program Specific Questions

Please answer the questions below, providing as many details as the space permits:

Why do you want to be an intern?*

What does being a part of this program mean to you?*

What are some of your interests and hobbies?*

If you take any medications during the day between 7:45am-3:00 pm Monday-Friday, are you able to take them on your own? If not, please explain.*

Write n/a if you do not take any medication

Are you able to manage your own personal care needs independently (such as dressing, eating, and using the restroom) without assistance?

Yes

No

Are you able to communicate independently in a work setting, with or without the use of assistive technology or reasonable accommodations?*

Communicate with Assistive Technology

Communicate with Assistance

Communicate Independently

Are you comfortable reading and writing in English as part of your job duties, with or without reasonable accommodations?

Yes

No

If you selected "Other" above, please specify:

How does your family/caregiver/natural support network support your work goals?*

Please share with us any concerns/worries you may have in participating and/or working in the community.*

Do you have any behaviors that might impact or affect a successful job placement? If yes, please explain.*

Other Services

Have you received services from BDI in the past? If so, which program?*

Are you currently enrolled with GA Vocational Rehabilitation Services (GVRA)?*

Yes

No

If yes, please list the name of your GVRA Counselor below:

If applicable, please enter your GVRA Counselor's email below:

If applicable, please enter your GVRA Counselor's contact number below:

Phone

Are you currently enrolled with Veteran Affairs Services (VA)?*

Yes

No

If yes, please list the name of your VA Counselor below:

If applicable, please enter your VA Counselor's email below:

If applicable, please enter your VA Counselor's contact number below:

Phone

Intern Program Commitment

If you are accepted into the program you will be required to agree to the following statement:*

I understand that if I am accepted into the program:

I will complete at least 3 paid internships at BDI's Elevate Academy.
I will attend the program every day from 7:45am-3:00 pm.
I will follow the dress code and arrive looking clean and neat.
I will contact my instructor and mentor when I am absent or tardy.
I will make up any assignments I miss if I am absent.
I will follow all the rules of the program.
I will attend all meetings with my counselor, parent/caregiver/guardian, teacher, skills trainers, and business staff.
I will participate in and discuss any issues at my meetings.
I will actively look for a job that in an integrated setting.
I understand that I must complete a background check.

I have read the statements above. I agree with these terms. I accept my placement in the program. I understand that I may be asked to leave the program if I do not follow these terms.

Do you have any concerns regarding the commitment to the program?

No

Yes

Are you willing to commit to working at least 16 hours per week after graduation?

Yes

No

Background Check Consent Form

The goal of the program is to provide training to help with job placement. BDI works with multiple companies across the Atlanta Metro Area. In order to expedite job, internship, and or apprenticeship placement, We ask that you complete the authorization for Background Check Form below:

Background Check Authorization*

I hereby DO authorize Bobby Dodd Institute to receive any Georgia criminal history information pertaining to me, which may be in files of any state or local criminal agencies in Georgia.

I hereby DO NOT authorize Bobby Dodd Institute to receive any Georgia criminal history information pertaining to me, which may be in files of any state or local criminal agencies in Georgia.

Please enter your 9 Digit Social Security Number:*

Please enter your height*

Please enter your eye color*

This authorization is valid for:*

180 Days from Signature

I do not authorize BDI to conduct a background check.

Background Check Signature*

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

Please type your name below:

Transportation

The primary purpose of the program is to provide interns with the opportunity for solid career exploration while developing skills essential to obtaining competitive employment and achieving success. As such, this transition program encourages interns to work towards independence, and that translates to feeling confident in managing transportation to and from work as independently as possible.

When an applicant is offered and accepts an employment offer it is critical that the applicant and those in his/her support system explore transportation options and, if necessary, identify and access travel training resources prior to the start of the program year.

Please check all that apply:*

I know how to use public transportation, such as MARTA, MARTA Mobility, etc.

I am willing to learn how to use public transportation, such as MARTA, MARTA Mobility, etc.

I currently use a door-to-door or paratransit service, such as MARTA Mobility, etc.

I have a family member or support person who is willing to help with my transportation on an ongoing basis.

I plan to use transportation provided by my home district, if available.

I have my own driver’s license.

I may be able to provide my own transportation to and from Elevate Academy.

I plan to use other forms of transportation, such as biking, walking, Uber/Lyft, or taxi.

I do not have access to transportation.

Release of Information

Authorization to Release and Obtain Confidential Information**

I understand that my records are protected under the Federal and State Confidentiality regulations and cannot be released without my written consent unless otherwise provided for in the regulations. Federal regulations prohibit BDI from making any further disclosure without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.

I further understand that my services are not contingent upon, or influenced by my decision to permit the information release, and by signing below, I indicate that my consent to the release of this information is given freely and voluntarily.

Please select below if you authorize BDI to obtain records on your behalf from the indicated school, agency, or individual below.

I hereby DO authorize BDI to obtain, to release, communicate, and exchange information or records on my behalf as indicated below.

I hereby DO NOT authorize BDI to obtain, to release, communicate, and exchange information or records on my behalf as indicated below.

Notice regarding educational records:

If the records to be disclosed are education records (which may include discipline records), they are maintained and released in accordance with the Family Educational Rights and Privacy Act (FERPA). Parents or eligible students shall be provided a copy of the records to be disclosed if requested. Redisclosure, except as provided at 34 CFR § 99.31, requires prior consent of parents or eligible students.

Please list your school's name or educational institution below:

I authorize BDI to communicate with the following agencies (Select all that apply):**

Georgia Vocational Rehabilitation Agency

Department of Behavioral Health and Developmental Disabilities (DBHDD)

Department of Veteran Affairs (VA)

Parent, Legal Guardian, or Authorized Representative

Other (Please specify below)

I do not authorize BDI to communicate with any agency regarding my information

Please list the name of agencies or individuals (Third Party) that you authorize BDI to obtain, to release, communicate with, and exchange information or records. (ex. ABC Medical Group, Dr. John Doe, Parent, Employer, etc.).

Purpose of Disclosure (check all that apply):*

Other Purpose of Disclosure

I authorize BDI to obtain records on my behalf for the following time period.**

Ninety (90) days

One (1) year

The period necessary to complete all transactions on accounts related to services provided to me

I do not authorize release of any records.

Release of Information Signature**

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document and authorize BDI to obtain, to release, communicate with, and exchange information or records identified in the release of information section.

Please note that if you indicated above that you do not authorize the release of records that this signature line acts as verification for BDI to not obtain records on your behalf.

Please type your name below:

Image and Photo Release and Use Agreement

Image Release*

I hereby grant and authorize Bobby Dodd Institute (BDI) the unrestricted right to take, edit, alter, copy, exhibit, publish, distribute, reproduce, and make use of any and all pictures, or video taken of me to be used in and/or for promotional materials. This includes but is not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalist, websites, social networking sites, and other print and digital communications, without payments or other considerations. I understand and agree that I have no right to be consulted about or approve of any such alterations before my image is used. This authorization extends to all languages, media, formats, and markets now known or hereafter devised. I understand and agree that these images shall become the property of Bobby Dodd Institute, and will not be returned.

Furthermore, I grant permission to use my statements that were given during an interview or survey, with or without my name, for the purpose of advertising and publicity without restriction. I understand and agree that BDI may use information regarding my health condition, including information regarding my diagnosis, services receiving/received, my date of birth and/or age and my other relevant disability information/conditions, in describing the services rendered to me as depicted in any image of me. I understand and agree that these statements shall become the property of BDI, and will not be returned.

This authorization shall continue indefinitely and in perpetuity, unless I otherwise revoke said authorization in writing.

I understand that BDI will make all reasonable efforts to safeguard my privacy as required by applicable law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand, however, that BDI cannot guarantee my complete privacy in the event my image or likeness is used by third parties.

I hereby agree to release, defend, and hold harmless Bobby Dodd Institute and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages, petitions, or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I attest that BDI has not conditioned the rendition of services to me upon my authorization of the use of my image and/or likeness and or statements.

I DO authorize and give BDI permission to use of my image, likeness, and/or statements.

I DO NOT authorize BDI permission to use of my image, likeness, and/or statements.

Inage and Photo Release Signature*

I am 18 years of age or older (or am the Parent/Legal Guardian) and I am competent to contract in my own name. I have read the foregoing in its entirety and understand its terms, before signing below, and I fully understand the terms, conditions, contents, meaning and impact of this release.

Please type your full name below:

Supporting Documentation (Upload)

Please upload electronic copy of your documentation of disability and/or other required documentation now by clicking on the upload button below. PDF of documents is the preferred method. Please do not submit documents in picture format as these are often not legible and are too large of a file size.

BDI requires verification of individual identification. Please select the following records you are able to provide. Please note that documents providing verification of identity must be attached in order for the application to be accepted. (Select all that apply)*

Driver's License or State Issued Identification

Birth Certificate

Social Security Card (Job and Career Services and Bridge Academy Only)

Required Document Acknowledgment Statement*

By checking this box below, I confirm that the following required documents have been attached to this BDI application.

File Upload*

Drag and drop files here or

How did you hear about us?

How did you hear about BDI?*

Select or enter value

Please provide the name of the individual or specific agency that referred you to BDI.

Application Submission

Do you understand that all applicants may not be accepted into this program?

If you are not accepted into the program one of BDI's team members will review other program options at BDI.

Yes

No

Electronic Signature

I acknowledge and warrant the truthfulness of the information provided in this application.

Please type your full name below.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

Thank you for completing the BDI Elevate Academy Application.

We recommend that you check the box below marked "Send me a copy of my responses." By checking this box a copy of your completed application and attachments will be emailed to you for your records.

We look forward to working with you!

Send me a copy of my responses