(A) Student Information/School Name:

(Last) (First) (Middle Initial)

(Address) (Birth Date)

(Phone & Cell) (Email Address)

(B) Eligibility: To participate in the Human Services Academy students must be seniors in good academic standing and commit to the following:

1. Will enroll and successfully participate in learning opportunities that may be available at your school. For example:

__ Psychology __ Sociology __ First Aid/CPR __ Tech Prep __ Other:__________

2. Will attend and complete training seminars presented by People Incorporated staff:

__ Medication Administration Program Certification (MAP)

__ Non-Violent Management of Aggressive Behavior (NVMAB)

__ Human Rights Training

__ First Aid/CPR

3. With parent/guardian approval, Academy students will participate in the work experience components offered by People Incorporated:

__ Job shadow at a residential facility for 4 hours

__ Complete a 12 hour internship at a residential facility

__ Participate in a mentoring relationship with a Residential Manager

__ Earn a favorable evaluation upon the completion of this component

(C) Graduation: Students will earn a Human Services Academy Certificate from People Inc. upon successful completion of all program components (1-3).

(D) Employment: Graduates of the Human Services Academy will be offered a career opportunity with People Inc and must document high school graduation, possession of a valid driver’s license and a qualifying CORI check.

(E) Post Academy: Once employed by People, Inc., Academy graduates may apply to

Bristol Community College’s 21-credit Human Services Certificate Program. Course tuition is significantly reduced for People, Inc. employees and will be fully reimbursed after each course has been successfully completed.

Please provide a paragraph elaborating on your personal reasons for applying to the Academy. You may wish to include relevant job history (if available), personal experiences, career aspirations, and/or knowledge of the human services field.

Student Signature: Date:

Parent/Guardian Signature: Date:

School Advisor Signature: Date:

People, Inc Signature: Date: