Arkansas REDI Program First Step, Inc. – Supported Employment Dear Applicant, We are so excited that you have decided to apply for the REDI program. Please take your time and carefully complete the application. We are here to help if you need it. After submitting this application, please make sure you contact Arkansas Rehabilitation Services (ARS) to begin the process of opening your case. An open case means that you have contacted ARS and have begun the process of becoming eligible for their services. ARS will determine within 60 days if you are eligible to receive their services. If you do not have an open case, please call ARS at 501-296-1600 to begin the process immediately. You will be assigned a counselor once your case is open. If you have already contacted ARS, please include your counselor’s name on your REDI application. Applications are due at least two weeks before the desired program session. Applicants between the age of 18 to 64 may apply for this program. All applicants who meet REDI criteria will be interviewed and assessed. You will receive a letter stating the date and time you are scheduled. You will be notified of the scheduled Interview and Hands-On Assessment Days. Please make sure you are available to attend. Once you are selected for an assessment, make sure you practice your interview skills and dress professionally. The REDI program can only have a limited number of externs each session. Sessions will take place throughout the year and admittance is based on completion of application and assessment process. You will be contacted on results and admittance. Please feel free to contact us if you have any questions regarding this application. If you would like more information about the REDI® Initiative in partnership with Arkansas Rehabilitation Services,please visit our website at www.firststeparkansas.com. Peggy Beggs REDI® AR Initiative, Director 501-609-9356 peggy.beggs@fstep.org or supported.employment@fstep.org Application Purpose and Guidelines The purpose of this application packet is to outline the skill set of the REDI applicant. This application enables the Selection Committee to properly assess each applicant’s skills, abilities, and background. A parent, applicant, counselor, teacher, or employer may be contacted by the selection committee to gather additional information. Our final goal is to select individuals who will be successful in the REDI program and reach the outcome of sustained, competitive employment. The Selection Process includes the following guidelines: 1. This application must be returned and approved before acceptance into the program. 2. Applicants must be between the ages of 18-64 years with an intellectual disability, developmental disability, and/or referral from ARS. The applicant must have finished high school and have received a high school diploma, GED, or certificate of completion (or is scheduled to graduate at the end of the current school year). He or she must demonstrate independent personal hygiene and grooming skills, have appropriate behavior, be able to get around independently and have the desire to work competitively. 3. The applications will be reviewed by representatives from First Step. 4. If accepted, the applicant must be able to pass a background check and drug screening. 5. If accepted, the applicant must have reliable transportation and must have an open case with Arkansas Rehabilitation Services (ARS). If an applicant does not already have an open case with ARS, they will need to begin the process before their application is considered. 6. Equal Opportunity: REDI Initiative in partnership with Arkansas Rehabilitation Services placement will be made without regard to race, color, national origin, sex, age, religion, or presence of a disability. PLEASE NOTE THE FOLLOWING IS A LIST OF ALL THE REQUIRED DOCUMENTS THAT MUST BE COMPLETED AND SENT TOGETHER FOR THE APPLICATION TO BE CONSIDERED COMPLETE Required Documents to be considered for the REDI Program: 1. Arkansas REDI: Application for Admission 2. ARS completed application referral form and required documents ARS Referral Form: dws.arkansas.gov/ar-rehabilitation-services Required documents: Photo ID Social Security Card Birth Certificate Proof of Income (SS/SSI Award Letter) 6 months of bank statements if you have a checking or savings account Current ATM Balance Inquiry Receipt Copy of card if you have a Direct Express or Pre-Paid Debit Card 3 years of verifiable rental history to include dates of residency and accurate contact numbers RIDAC Medical Assessment Referral letter Authorization for services 3. Optional:Any other documentation that may help us in the decision-making process may be emailed to First Step at supported.employment@fstep.org. Please make sure to include your name and reference the REDI Program in your email. (Documentation may include latest testing, IEP, reference, resume, etc.) Completed Application must be received and approved by the start date of the desired program session. For questions or additional information: Peggy Beggs, First Step, Inc. 501-609-9356 or supported.employment@fstep.org AR REDI ApplicationPERSONAL DATA Applicant Contact Information: Name(Required) First Last Birth Date:(Required) MM slash DD slash YYYY Gender(Required) Male Female AgeEthnicity Social Security NumberPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent Contact Information: Name First Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Guardian Contact Information (If different from parent): Guardianship: I am my own guardian I am not my own guardian* * You will need to provide legal documentation of guardianship if you are accepted into the program.Guardian Name First Guardian Relation First PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Government Benefits Received: SSI SSDI ACS-HCBS (Medicaid) Waiver Do you have an Arkansas Rehabilitation Services Vocational Rehabilitation Counselor?(Required) Yes No Name First PhoneEducation Background: Have you graduated from high school?(Required) Yes No If yes, what HS did you graduate from? Date Graduated: MM slash DD slash YYYY What type of degree did you receive?(Required) GED Certificate of Completion High School Diploma If no, what HS are you currently attending? Date you will Graduate: MM slash DD slash YYYY What type of degree will you be receiving? Other Education/Program: Date: MM slash DD slash YYYY Work Background: List jobs (paid or unpaid) you currently do or have done in school or in the community: ListEmployerJob TitleJob DutiesSupervisor NameContact NumberPaidUnpaidHow long were you at the job?ListEmployerJob TitleJob DutiesSupervisor NameContact NumberPaidUnpaidHow long were you at the job?ListEmployerJob TitleJob DutiesSupervisor NameContact NumberPaidUnpaidHow long were you at the job?Have you ever been fired from a job? Yes No If yes, please explain: Have you ever quit a job? Yes No If yes, please explain: Transportation How do you plan to get to the REDI Program training? Public Transit Parent/Family Drive Self Other Diagnosis/SymptomsPrimary Diagnosis: Secondary Diagnosis (additional disability, mental health conditions or medical conditions): Please Complete in Your Own Words:Why do you want to participate in the REDI Program? How did you hear about the REDI Program? Reference Information Please provide the name and contact information of a non-related individual to complete an applicant assessment (Example: teacher, neighbor, previous employer, etc.) Name First Last PhoneEmail Applicant’s position within the program is contingent upon adherence to the policies and procedures of First Step, Inc. and the REDI program. By signing, the applicant and/or guardian agree to comply. Representatives of First Step, Inc. have my permission to share my information with designated representatives of Arkansas Rehabilitation Services (ARS) during the application/selection process, and if selected during my participation in the training, employment planning, and follow-along services.Applicant SignatureDate MM slash DD slash YYYY Legal Guardian Signature (If applicable):Date MM slash DD slash YYYY Did anyone help you to complete this application? Yes No Name of Individual: First Relationship: PhoneEmail Applicant’s Participation Contract I, , understand that if I am accepted into the REDI program, I must abide by the following terms and conditions: Untitled(Required) I understand that the REDI Program is a 4-week work/educational program, and I will actively pursue competitive employment when I have completed the program. I will complete the extern training at the assigned Walgreens site. I will attend the program every day as scheduled. I will dress appropriately and wear the required attire. I will call my job coach if I will be absent or tardy. I understand that I am responsible for transportation to and from the assigned Walgreens site. I will follow all rules established by the program. I will attend and be an active participant at meetings with my rehabilitation counselor, parents, job coach, and Walgreens staff. I will be able to pass a felony background check. Consent(Required) I have read the above terms and conditions and agree with what has been stated. I understand that I may be asked to leave the REDI Program if I fail to follow the terms and conditions.(Required)Applicant SignatureDate MM slash DD slash YYYY Parent/Guardian SignatureDate MM slash DD slash YYYY 84044
