Positive Vibe Café Training Program

Applicant Information

Date of Birth:                         /                /                Age: _______     Sex: _________ Race: ________________________

Applicant Name:                                  _________________________________________________________________________

Address:                                                                                                          County:______________________________________

 City:                                             State:                        Zip:_________                                                                                      ______

 Phone Number:                                                                       Email:                                                                             _____________

Parent/Guardian:                                                                                                                                                                                   _

Phone Number:                                                                       Email:                                                                                                        _

 School:                                                                                                                                 Grade Completed:                     

or Date graduated:            _____

 School IEP Case Manager: ______________________________________________________________________

 Phone Number:                                                                      

Email:                                                                                                                                    ______

DRS or CSB Case Manager/Counselor:                                                                                                Agency:                                    _____

Phone Number:                                                                       Email:                                                                                                         ______

Most recent IEP/evaluation date:               /                /               

Applicant’s Disability:                  _                                                                                                                                                           ______

Medication/ Allergies:                                                                                                                                                                                ______ 

Applicant Info:

                  Lift 5-10 lbs?                                    Read/write English?

                  Work in group setting?                      Participate in a hands-on classroom for 2 hours?                                                                                              Have transportation?  Who is providing transportation? __________________________________________________________

                  Need adaptations?                                                                                                                                                                            

Education:                                                                                     School:                                                         Dates:                                           Previous Employment:                                                                                                                                                                                        _

                                                                                                                                                                                                     ___________

                                                     ___________________________________________________________________________________

Volunteer/Training experience: ________________________________________                        ____________                                            

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Schedule Conflicts:                                                                                                                                                                                                                                                                                                                                                                                                                             

Emotional issues/history:                                                                                                                                                                            ______

                                                                                                                                                                                     ______ _____________

Emergency Contact:                                                                                                                                                                               ______

Phone Number:                                                                                         Cell Phone:                                                                                            

Email:                                                                                                                                                                                                                    

Comments:                                                                                                                                                                                                           

Additional Information:

Does the student have any communication/technology needs?                                                                                          _____________

If so,  what?                                                                                   _                                                                                                                     

Does the student have any disruptive personal or classroom behavior(s)?                                                  _____________

If so,  what?                                                                                                                      _                                                                                   

Is the student blind, or have a visual impairment?              YES         NO

Is the student deaf, or have an auditory impairment?                       YES         NO

What are the student’s employment or education goals?                                                                                                                           Accommodations  that work                                                                                                                                                                                      

Notes:                       ____                                                                                                                                                                                  

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________ 

How did you hear about PVC Training? ___________________________________________________________  ___________________________________________________________________________________________

Return application to:

Training Director

Max's Positive Vibe Cafe

2825 Hathaway RoadRichmond, VA 23225

Fax: (804) 560-9623Phone: (804) 921-1629 Training

      (804) 560-9622 Cafe