BDI's Elevate Academy

Admissions Application




๏ปฟThank you for your interest in Elevate Academy at Bobby Dodd Institute!



Elevate Academy is new BDI initiative aimed to combine workplace readiness, work adjustment training and career pathway exploration with job placement and ongoing coaching creating a clear pathway to long-term, meaningful employment.


Selection Priorities:


  • Ages 18 through 30
  • Eligible for Vocational Rehabilitation (VR) services
  • Individuals who are able to work independently
  • Ability to develop a transportation plan



The Application Process:


Step 1: Please complete this online application.


Step 2: Complete a short online assessment. This will be sent to you after application.


Step 3: BDI will review your application to determine eligibility.


Step 4: Upon eligibility you will be scheduled for an assessment. More details will be provided.


Step 5: BDI will notify you on intern selection.

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


Demographic Information

Who is completing this application*

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

Gender:*
Ethnicity/Hispanic Origin:*
Do you need an interpreter?*
Are you currently or have you ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard?*
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.

T-Shirt Size*

Disability Information


Check which one of the following disability categories is most relevant to the identified individual.


Contact and Address Information

GA
Caret IconCaret symbol
Select or enter value
Caret IconCaret symbol
Phone
Phone
How do you prefer us to contact you?*
Do you authorize BDI to communicate with you via email?*
Current Living Arrangement*

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

Select or enter value
Caret IconCaret symbol

Parent or Legal Guardian Information, if applicable

Do you have a Legal Guardian?*
Phone
Do you authorize BDI to communicate with you via email?

Emergency Contact Information

Emergency Contact Relationship to Applicant*
Phone

Education and Work History

Education Level*
Do you have documentation of your education (diploma/transcript) that you can provide.*
Currently Attending High School?*

What is your current employment status?*
Are you legally able to work in U.S.?*
Are you currently employed or have you been previously been employed?*

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:

Write n/a if you do not take any medication

Please check ALL sources of the individualโ€™s current natural support network:


Other Services

Are you currently enrolled with GA Vocational Rehabilitation Services (GVRA)?*
Phone
Are you currently enrolled with Veteran Affairs Services (VA)?*
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 unpaid 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?


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*
This authorization is valid for:*

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.


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.

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 ยง 99.31, requires prior consent of parents or eligible students.


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

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

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 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.

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

Drag and drop files here or

How did you hear about us?

Select or enter value
Caret IconCaret symbol

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.

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!