S.T.A.R.S. Application
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“Students
Transitioning to Adult Responsibility and Success”
Student Name:
Date of Birth:
Address:
E-mail Address:
Phone Number:
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Emergency Contact Name:
Relationship to Student:
Address:
E-mail Address:
Phone Number:
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School District:
Address:
E-mail Address:
Phone Number:
School District Contact Person/Title:
E-mail Address:
Phone Number:
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About the Student:
Disability:
Is there a current IEP? Yes No (If
yes, please include with application.)
Medical Concerns/Considerations:
What are the students needs?
What skills would you like to see the student work to develop/ improve?
Will there be parental involvement? Yes No
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Attendance Schedule: Daily
Half Days
Other Please
explain:
Anticipated Days of Attendance: Monday Tuesday
Wednesday
Thursday Friday
What is the anticipated date for the student to start the program?
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What are the anticipated transportation arrangements:
The school will provide transportation. ____
Transportation arrangements will be negotiated with the S.T.A.R.S. program.
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*The information provided on this application will begin the planning
process for service delivery. There will be additional forms
to be completed
once this information is provided and attendance is confirmed.
Signature of Person Completing Application
Date
