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Center For Success
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We provide an environment of engagement and purpose.
APPLICATION DOCUMENT CHECKLIST
Application Procedure
Admission Agreement
Melba Lee Inc. Center for Success Application – signatures needed
Applicant’s Skills Inventory – to be completed by parent/guardian/staff
Applicant’s Needs – to be completed by parent/guardian/staff
Typical Day of Applicant – to be completed by applicant
Complete the information below:
DATE REQUESTED:
MM
DD
YYYY
DATE APPLICATION WAS PROVIDED TO APPLICATANT:
MM
DD
YYYY
NAME OF APPLICANT:
*
First Name
Last Name
POTENTIAL START DATE:
MM
DD
YYYY
NUMBER OF DAYS YOU WILL BE ATTENDING:
DO YOU NEED TRANSPORTATION SERVICES?
Yes
No
Not sure
SUPPORT COORDINATOR NAME AND PHONE NUMBER:
First Name
Last Name
(###)
###
####
STAFF PRINT YOUR NAME WHEN DELIVERED:
Yes
No
Not sure
ADDITIONAL INSTRUCTIONS (if any):
Application Procedure
Step 1 Attend Melba Lee Inc. Center for Success Program Tour. Both the applicant and his or her parent(s) or guardian(s) should attend Melba Lee Inc. Center for Success (ADT) tour before applying to the program. The applicant and parent/guardian must have attended this tour within one year of applying. During this tour, all aspects and goals of the program will be reviewed and discussed during a presentation with an opportunity for questions and answers by the Melba Lee Inc. staff. Step 2 Request and Review, Melba Lee Inc. Center for Success Application Packet: The application packet can be picked up or request to be mailed. All required documents of the Application Packet must be submitted together to complete the process for admission. It is important that the most current information is submitted in order to determine that Melba Lee Inc. Center is an appropriate placement and that the applicant has the combination of desire, motivation, skill, and experience to be successful in the program. Once Melba Lee Inc. staff has reviewed the completed application packet, one of the following will take place: - The applicant and parent(s) or guardian(s) will be contacted to set up an interview for admission. - The applicant was not selected and may be encouraged to reapply or be placed on a waiting list. Step 3 Participate In 30 Days Assessment: Both the applicant and the Melba Lee Inc Program Manager will meet with the applicant’s Waiver Support Coordinator to evaluate the program placement and establish program goals to be included in the Individual Program Plan or Implementation Plan.
ADMISSION AGREEMENT FOR:
Melba Lee Inc. Center for Success is a Day Training Activity Center for adults with developmental disabilities, licensed by the Agency for Persons with Disabilities (APD). This facility is not licensed for, and will not provide nursing care. We are located at 1404 Tech Blvd Tampa, FL 33619. Our telephone number is 813-542-1000 Our business hours are 8:00a.m. to 3:00 p.m. Monday through Friday. Program hours for consumers is base on 6 hour per day. We are closed on holidays mandated by the State of Florida. We agree to provide the following basic services for the above-named applicant: - Training in life skills related to the Support Plan goals. - Training in employment readiness. - Training in health and wellness. - Training in the use of technology. - Plan goals. These goals will be reviewed at least annually and revised as necessary. - Provide continuous observation, care and supervision as required. Provisions of our services are subject to the applicant’s continued eligibility as stated in our Entrance and Exit Criteria. Enrollment eligibility may vary in some cases from the basic Entrance and Exit Criteria if extenuating circumstances are present. Enrollment requirements include, but are not restricted to: - Applicant must be able to follow directions and redirection. - Applicant will be committed to good attendance, not to exceed 25 program days annually excluding holidays. - Applicant will not be a danger to self or others. - Applicant will not be prone to stealing or destroying personal or facility property. - Applicant will satisfactorily complete a 30-day probationary enrollment period. - Applicant agrees to abide by Melba Lee Inc. Center for Success’s Behavior & Attendance Policy contained in this packet. - Applicant must have acceptable social behavior, verified by previous schools, family, and/or agency personnel as well as the ability to get along with peers, follow rules, and accept supervision. - Applicant must be able to participate in a personal interview. Multiple approaches will be used in determining ongoing enrollment in this program. Except in cases where the applicant may be a danger to self or others, a 30-days notice will be given for our intent to dismiss an applicant from this program. Applicant must agree to comply with the general policies of the facility. They are not to bring medications, special foods or beverages into the facility without the knowledge of the program administrator. Melba Lee Inc. will not be responsible for any cash, valuables or other personal property brought to the Center unless these items are delivered to administration for safekeeping. A two-week notice of intent to leave this program is requested unless the applicant’s physical or mental condition prevents this. My signature below as “Applicant” and/or “Applicant’s Authorized Representative” indicates that I have read, or had read and explained to me, the provisions of this agreement and enter this agreement voluntarily. SIGNATURES OF PARTIES TO THIS AGREEMENT:
Applicant or Authorized Representative:
Date
MM
DD
YYYY
Melba Lee Inc. Center for Success, Administrator:
Date
MM
DD
YYYY
*Note: The original agreement shall remain on file with Melba Lee Inc. Center for Success and a duplicate copy shall be given to the applicant and/or the applicant’s authorized representative
MELBA LEE INC. CENTER FOR SUCCESS APPLICATION
*To ensure that the application is processed, applicant and/or parent/guardian must complete all information
Please check the box below to tell us how you found out about Melba Lee Inc. Center for Success (ADT):
Melba Lee Inc. Center for Success Website
APD
Wavier Support Coordinator
Waiverprovider.com
Internet Search
Another Website
Past/current Melba Lee Inc. Center for Success Students/Family
Other
IDENTIFYING INFORMATION
Applicant Name:
First Name
Last Name
Date of Birth:
MM
DD
YYYY
Age:
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Applicant’s Home Phone:
(###)
###
####
Applicant’s Cell Phone:
(###)
###
####
Applicant’s Email Address:
Sex:
Male
Female
Other
Copy of Applicant’s ID:
Yes
No
Not sure
Height:
Weight:
Legal Competency:
Language Spoken in the Home:
PARENT OR GUARDIAN INFORMATION
Name:
First Name
Last Name
Relationship:
Primary Contact:
Yes
No
Not sure
Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone:
(###)
###
####
Cell Phone:
(###)
###
####
Work Phone:
(###)
###
####
Email Address:
Name:
First Name
Last Name
Relationship:
Primary Contact:
Yes
No
Not sure
Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone:
(###)
###
####
Cell Phone:
(###)
###
####
Work Phone:
(###)
###
####
Email Address:
PHYSICIAN'S INFORMATION & MEDICAL HISTORY
Primary Care Physician (PCP):
PCP Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
PCP Phone Number:
(###)
###
####
In case of emergency what is your hospital preference name and address:
Did you receive the Hepatitis B vaccine?
Yes
No
Not sure
Results of Hepatitis B test:
Positive
Negative
Not sure
Are you a known carrier of any disease? (If applicable, please list):
Do you have any special dietary needs? (If yes, please list):
Do you have any food allergies?
Yes
No
Not sure
If yes, please list all food allergies:
Do you have any medication allergies:
Yes
No
Not sure
If yes, please list all medication allergies:
LIST OF MEDICATIONS (please include dosage, time and reason):
PHYSICAL SUPPORTS?
*Please check all that apply.
Uses Manual Wheelchair
Uses Electric Wheelchair
Uses Walker
Uses a Cane
Uses Handrails in Bathroom & Shower
Do you wear Glass?
Do you wear Contacts?
Do you wear Hearing Aid?
Are you continent or incontinent?
Requires Other Supports? (If yes, please specify):
BEHAVIOR
*Please check all that apply.
Lack of motivation
Non-compliance
Inability to self-regulate
Argumentative
Inconsistency and/or resistance to following prescribed medication times
Anxiety
Verbal Outbursts/Cursing
Fabrication
Difficulty with self-regulation; e.g., food, buying unnecessary items, engaging in video games, etc.
Obsessions/Compulsions
Dysfunctional Eating Habits
Verbally threatened others
Self-injurious behavior
Bladder Incontinence/difficulties
Bowel incontinence/difficulties
Requires attendant care
Physically threatened and/or attacked others
Bullying
Mistreats animals
Elopement
Lying
Inappropriate sexual behaviors (Including the internet)
Stealing (Money, food, personal belongings, etc.)
Tobacco use/abuse
Marijuana use/abuse
Drug use/abuse
Alcohol use/abuse
Caused property damage including starting fires, punching walls, throwing objects
Prior arrest or probation
Current gang behavior, affiliation and desires
If yes to any of the behavioral and/or self-care issues, please explain in detail. Include the most recent date(s) of the occurrences and severity (use another sheet for more writing space):
Applicant Skills Inventory
Applicant Name:
First Name
Last Name
Person Rating Applicant:
First Name
Last Name
Date:
MM
DD
YYYY
Relationship to Applicant:
Directions
Use the following rubric to provide a score regarding the applicant’s level in Skill Acquisition and a score regarding the applicant’s skill level in Task Completion. For Skill Acquisition, the scores range from 1-6, with “6” indicating that the applicant does not yet have any experience in learning the skill and “1” indicating that the applicant can consistently demonstrate the skill without any support. For Task Completion, the scores range from 1-6, with”6” indicating that the applicant does not yet have any experience in completing the task and “1” indicating that the applicant can consistently demonstrate completion of the task without any support.
Skill Acquisition
Score & Description: (6) No Experience Yet *Applicant does not yet have experience in learning how to do the task. (5) Non-Compliance *Applicant shows no-compliance in the form of arguing, delaying, ignoring, refusing, or other forms of resistance, in earning how to do the task. (4) Linguistic Prompting *Applicant requires linguistic prompting in the form of specific verbal instructions and/or spoken cues in learning how to do the task. (3) Manipulate Prompting *Applicant requires manipulate prompting in the form of modeling, moving materials for the applicant, and/or partial physical cues in learning how to do the task. (2) Indirect Prompting *Applicant requires indirect prompting in the form of gesturing, visual aids, and/or the close proximity of an observer in learning how to do the task. (1) Demonstrated Independence *Applicant has demonstrated independence of the skills needed to complete the task in the presence of a non-interfering observer.
Task Completion
Score & Description: (6) No Experience Yet *Applicant does not have experience in learning how to do the task. (5) Non-Compliance *Applicant shows non-compliance in the form of arguing, delaying, ignoring, refusing or other forms of resistance, in completing the task. (4) Reminders *Tasks are completed after a reminder is provided or pointing out that a task should be done. (3) Schedule *Tasks are completed per a predetermined schedule regardless if those tasks should necessarily be completed or not. (2) Parameters *Task are completed via the use of parameters to determine if tasks should be completed or not. (1) Demonstrated Independence *Applicant has demonstrated independence by completing tasks with a functional schedule and/or as determined necessary by using parameters.
Directions
For each of the items below, type in two scores in the form of a number from 1 to 6 for both the Skill Acquisition Score followed by the Task Completion Score in the appropriate box (ex. 6, 5) . This should be to best estimation of the level of the student in each item as related to Skill Acquisition and task Completion.
Cleaning his/her own bedroom
Cleaning his/her own bathroom
Cleaning the kitchen
Cleaning the living room
Keeping clothing clean and organized
Keeping bedding clean and regularly changing bedding
Maintain personal hygiene
Wear proper attire (based on the activity, weather, etc.)
Use morning, evening, and/or other routine
Visit self-care professionals (barbers, salons, etc.)
Using and maintaining a meal plan
Using and maintaining a meal plan
Going grocery shopping regularly
Cooking meals regularly
Cooking meals regularly
Demonstrating safety awareness in the kitchen (heat safety, cutlery safety)
Use a bank account and its associated debit card
Budgeting regularly and appropriately
Checking the mailbox regularly and sorting incoming mail
Self-advocating in a shared living situation
Reaching mutual agreements in a shared living situation
Self-administering own medication as prescribed or recommended
Obtaining more medication by renewing or refilling
Completing the application process for a job including an interview
Creating a continually updating a resume
Obtaining proper clothing for work experience
Attending and participating at a job for 7 or more hours a week
Monitoring paychecks and depositing them into a bank account
Transporting self back and forth from home and work
Choosing classes to enroll in (college or otherwise)
Requesting accommodations in an academic setting
Using and maintaining or organized binder
Navigating a campus to find classrooms
Attending and participating in class session (college or otherwise)
Planning and completing assignments by their due date
Writing a one-page reflection paper
Planning social activities or get-togethers with others
Attending and participating in social activities
Using public transportation (buses, taxis, Uber/Lyft, etc.
Attending and participating in volunteer hours
Structuring free time to develop personal interests
Using a fitness routine regularly
I have completed this Applicant Skill Acquisition & Task Completion Inventory truthfully and to the best of my knowledge all information is accurate. I understand that falsifying or omitting information could be grounds for termination from the program.
Person Rating Applicant :
Signature:
Date:
MM
DD
YYYY
Applicant’s Needs
WHAT ARE THIS APPLICANT’S NEEDS? (To be filled out by parent/guardian advocate) What are the applicant’s strengths and their areas of need? Please describe in detail any previously used supports, accommodations, and/or behavior/management plan. List any types of assistive technology utilized. If you need more space, please attach an additional page.
Typical Day of Applicant
WHAT DOES YOUR TYPICAL DAY LOOK LIKE? (To be filled out by applicant) What would a typical day be like for you? Please include all current pertinent recreational activities as well as areas of interest. If you need more space, please attach an additional page.
RACE AND ETHNICITY TRACKING (Optional)
For purposes of data collection for occasional funding, please mark the box(es) that best describes the applicant’s race/ethnicity category of which she/he identifies with:
Asian or Pacific Islander: Persons having origins in any of the peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa.
African American (not of Hispanic origin): Person having origins in any of the black ethnic groups.
Hispanic: Persons having origins in any of the Mexican, Puerto Rican, Cuban, Central or South American or other Latin Cultures, regardless of ethnicity.
Native American or Alaskan Native: Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.
Caucasian (not of Hispanic origin): Persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
I have completed Melba Lee Inc. Center for Success application truthfully to the best of my knowledge, all information is accurate. I understand that falsifying or omitting information could be grounds for termination from the program.
Applicant Print Name:
Applicant Signature:
Date:
MM
DD
YYYY
Parent/Guardian Print Name:
Parent/Guardian Signature:
Date:
MM
DD
YYYY
Parent/Guardian Print Name:
Parent/Guardian Signature:
Date:
MM
DD
YYYY
Thank you!
