Post on 26-Mar-2018
BridgetoIndependence
1Revised2-1-17
BridgetoIndependence-DiplomaProgramAdmissionProcedureTheBridgetoIndependenceDiplomaprogramatNichollsStateUniversityisanoptionalacademicandsupportservicefordegreeseekingstudentswithAutismSpectrumDisorder(ASD).Criteria
• StudenthasbeenacceptedtoNichollsthroughtheregularadmissionsprocess• Age18-28• StudenthasadiagnosisofAutismSpectrumDisorder(ASD)asindicatedonacurrent
(withinthreeyears)psychologicalevaluation• Personalmotivationforsuccess• Personalaccountability• Opennesstoreceivesupport• Abilitytomaintainpersonalsafety
BridgetoIndependence
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STEP#1InitialCriteriaIftheinitialcriteriaaremet,theapplicantmayapplydirectly.Theapplicationinstructionsandformscanbeaccessedonlineatwww.Nicholls.edu/BridgetoIndependenceorbyemailing:Dr.MaryBreaudatmary.breaud@nicholls.eduTheApplicationPacketincludes:•BridgeDegreeprogramApplication•PersonalStatementInstructions•ReferenceLetter(Print2oftheseforms)•ReferenceLetter-Waiverform•AuthorizationtoReleaseStudentInformationform•Applicant’sSkillInventory•GraffParentReadinessScale(GPRS)•ScopeofServicesSTEP#2ProgramTour:TheapplicantandfamilymustattendaBridgeprogramTour.Duringthetour,allaspectsandgoalsoftheprogramwillbereviewedanddiscussed.Atourofthecampusandresidencehallswilltakeplacewithanopportunityforquestionsandanswersbythestaff.ThetoursarescheduledthroughouttheyearandattendingismandatorybeforebeingconsideredfortheBridgeProgram.CalltheNichollsAdmissionsOfficeat985-448-4507toscheduleatour.AdmissionPacket:AllrequireddocumentsmustbesubmittedtogethertocompletetheprocessforadmissionconsiderationtoBridge.ItisimportantthatthemostcurrentinformationissubmittedinordertoascertainthattheBridgeProgramisanappropriateplacementandthatthestudenthasthecombinationofdesire,motivation,skill,andexperiencetobesuccessfulintheprogram.Documentsandcompletedformsrequiredattimeofsubmission:1.BridgetoIndependenceApplication2.Recent5”X7”photograph3.AuthorizationtoReleaseStudentInformationform-signed&dated4.BridgetoIndependenceSkillInventory5.PersonalStatement.Thisistheapplicant’sopportunitytostatereasonsforwantingtoattendBridgeandprovideadditionalpersonalinformation.Becreative!Thiscanbehandwrittenortypedbytheapplicant,aportfolio,videorecordedontoaflashdrive(noDVD/CD’sastheywillcrackinthemailingprocess),etc.Themaximumallowedtimeforvideorecordedpersonalstatementsis5minutes
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8.Current1508specialeducationevaluationorevaluationfromprivateproviderwithfullassessmentdataandexitIEPfromHighSchoolifstudentattendedpublicschoolSubmissionrequirements:•Submitallrequiredmaterialsinonepacket•Allofthematerialsmustbethoroughlycompleted•IncompleteapplicationswillnotbeprocessedSTEP#3OncethecompletedadmissionpackethasbeensubmittedandreviewedbytheBridgestaff,notificationletterswillbemailedtoallapplicants.Theletterwillstateeither:•Theapplicantandparent(s)orguardian(s)willbecontactedtosetupthenextstepintheprocess,whicharetheinterviews,STEP#4–ApplicantswhoareselectedtobeinterviewedTheapplicantwillbeinterviewedseparatelyfromtheirparent(s)/guardian(s).Theinterviewprocesswillascertain:•Thatthestudenthasthedesire,abilityandmotivationtoparticipateintheprogram•Thatthestudent’sindividualneedscanbeappropriatelyservedbytheprogramstaffand/orcommunityanduniversityresources.•Thestudentispreparedtoentertheprogram.•Thestudentmeetstheentrancerequirements.
ResultsNotificationUponcompletionoftheinterviews,notificationwillbesenttoeachapplicantinatimelymanner.Pleasebepatient.Thisisadauntingprocess.Weareweighingourdecisionscarefully.Pleasemailcompletedpacketsto:
BridgetoIndependenceatNichollsStateUniversityAttention:Dr.MaryBreaud,Ed.D
CollegeofEducationP.O.Box2053
Thibodaux,LA70310
BridgetoIndependence
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BridgetoIndependenceApplication
To ensure that the application is processed, applicant and/or parent/guardian must complete allinformation(Raceðnicitytrackingisoptional).
DateattendedaNichollstourandprogramoverview:_____________________
IDENTIFYINGINFORMATIONApplicantName:
Birthdate:
StreetAddress: Age: City: State: Phone: () ApplicantsCellPhone:() Male/FemaleApplicant’sEmailAddress:
Driver’sLicense: Yes/No
U.S.Citizen: Yes/No CountryofCitizenship:
LanguagesSpokenintheHome: AreyouConserved: Yes/NoAreasConserved:
Conservator’sName:
RelationshiptoApplicant:
PARENTINFORMATIONParent#1orGuardianName: Address: EmailAddress: PrimaryPhone# () EmailAddress:
Parent#2: Address: EmailAddress: PrimaryPhone# () CellPhone#:()
SIBLINGINFORMATIONNameofSibling(s) Age LivesatHome
Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
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EDUCATION&SERVICES NameofInstitution DiplomaHighSchool: CollegeorProgram:
HighSchoolCompletionorProjectedDate:
SubjectStrengths:SubjectWeaknesses:
DoestheapplicanthaveaLouisianaMedicaidwaiver? Yes/NoIfyes,CaseManagementAgencyName:
Phone#: ()
Address: CaseManager’sName: EmailAddress: Fax#: DirectServicesProvider: Yes/No Direct
ServiceProviderAgencyName:
Address: Phone#: ()EmailAddress: Fax#: ()IsaclientofLouisianaRehabServices:
Yesq Noq InProcessq
Address:
LRSCounselorName: Phone#: ()
Email: Fax#: ()
DoyoureceiveSSI:
Yesq Noq InProcessq Willapplyq
IfYes,NameofPayee: AmountPerMonth: $
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VOLUNTEER&COMMUNITYSERVICE
Organization DescriptionofActivityandDuties Hours/PerWeek
WORKEXPERIENCEBusiness/Organization Duties DatesEmployed Hrs/Wk
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MEDICATIONINFORMATIONDoYouTakeMedication(s): Yesq Noq
NeedsAssistanceWithMedications:Yesq Noq Ifyes,pleaseexplain:
Medication(s) TimesofDay/Week Purpose
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BEHAVIOR
Causedpropertydamageincludingfires YES NOPhysicallythreatenedand/orattackedothers Verballythreatenedothers Self-injuriousbehavior Mistreatinganimals Elopement Lying Fabrication Inappropriatesexualbehavior Stealing Priorarrestorprobation Tobaccouse/abuse Marijuanause/abuse Druguse/abuse Alcoholuse/abuse Seizure(s) Currentgangbehavior,affiliationanddesires Incontinenceproblems Requiresattendantcare Consistentlyfollowsverbaldirections Ifyestoanyofthebehavioralandorself-careissues,pleaseexplainindetail.Includethemostrecentdate(s)oftheoccurrence(s)andseverity(useanothersheetformorewritingspace):
BridgetoIndependence
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RACEÐNICITYTRACKING
OPTIONALForpurposeofdatacollectionforBridgetoIndependencefunding,pleasemarkthebox9es0thatbestdescribestheapplicant’srace/ethnicitycategoryorwhichhe/sheidentifieswith:A___ AsianorPacificIslander:PersonshavingoriginsinanyofthepeoplesoftheFarEast,
SoutheastAsia,theIndiansubcontinent,orthePacificIslands.Thisareaincludes,forexample,China,Japan,Korea,thePhilippineIslandsandSamoa.
B___ AfricanAmerican(notofHispanicorigin):Personhavingoriginsinanyoftheblackethnicgroups.
H___ Hispanic:PersonshavingoriginsinanyoftheMexican,PuertoRican,Cuban,CentralorSouthAmericanorotherLatinCultures,regardlessofethnicity.
I___ NativeAmericanorAlaskanNative:PersonshavingoriginsinanyoftheoriginalpeoplesofNorthAmerica,andwhomaintainculturalidentificationthroughtribalaffiliationorcommunityrecognition.
W___ Caucasian(notofHispanicorigin):PersonshavingoriginsinanyoftheoriginalpeoplesofEurope,NorthAfricaortheMiddleEast.
IhavecompletedthisBridgetoIndependenceDiplomaprogramapplicationtruthfullyandtothebestofmyknowledgeallinformationisaccurate.ApplicantSignature:_________________________________________________Parent/GuardianSignature:____________________________________________Date:____________________
BridgetoIndependence
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PersonalStatementInstructions
Animportantpartoftheadmissionsprocessisthepersonalstatement.ThisisyouropportunitytoshinebytellingwhyyouwanttocometotheBridgeProgramaswellassomethingaboutyou.Thisincludesfactsaboutyourbackground,goals,andanyotherinformationthatyouthinkwillhelpuslearnmoreaboutYOU.BECREATIVE.Thepersonalstatementcanbehandwrittenortyped,aportfolio,videorecorded,etc.Anyelectronicsubmissionsmustbeonaflashdrive,asaDVD/CDwilleasilybreakduringthemailingprocess.Themaximumallowedtimeforvideorecordedpersonalstatementsis5minutes.Materialssubmittedwillnotbereturned.Yourpersonalstatementmustincludenumbers1–4and11below.5-10areoptional.1.Yourname.2.WhyyouwanttoparticipateintheBridgetoIndependenceDegreeprogram.3.Specialinterests.4.Includespecificareasoractivitiesyouwouldlikeparticipateinwhileintheprogram.5.Describe1-2opportunities/tripsyouhavetakenwithoutyourparents/family.Include: •#ofdays •Destination •Purpose(e.g.vacation,conference,etc.) •Howyoufeltaboutbeingaway •Whoyoutraveledwith •Modeoftransportation6.Thingsyouliketodoinyourfreetime.7.Inschool,nameyourfavoritesubject(s)andyourleastfavoritesubject(s).8.Yourstrengths.9.Areasyouwouldliketoimproveupon.10.Describewhatyoulearnedandenjoyedaboutanypaidand/orvolunteerworkexperience.11.Describewhatyouseeasyourideallifeinthefuture? •Wherewouldyouliketowork? •Wherewouldyouliketolive?ACity,Apartment,condominium,homeandwouldyouliketo livewitharoommates,familyoralone.
BridgetoIndependence
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CaseManagementStateAgencyReferralForm(ifapplicable)PleasereviewadmissionscriteriabeforereferringyourclienttotheBridgetoIndependenceProgram(Bridge)atNichollsStateUniversity.
Attachthemostcurrentstatereportforthisclient.ClientName:UCI#:Age:Diagnosis:Fax:()Address:NameofServiceCoordinator:Phone#:()Email:NumberofMonthsorYearstheApplicanthasbeenyourClient:ClientName: ID/Case#: AGE: Diagnosis: NameofAgency: Fax#: ()Address: NameofCaseManager: Phone#: Email: Numberofmonthsoryearstheapplicanthasbeenyourclient?: 1.Whataretheclient’smostexemplarytraits?2.Whataresomeareasforimprovement?3.Stateanyfactors/characteristics/behaviorsofthisclientthatwouldbeaconcernforBridge?Pleasebeveryspecific.4.Statereasonswhyyoufeeltheclientisorisnotappropriate/readyforBridgeatNichollsState?
BridgetoIndependence
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5.Isyourclientreadytomoveoutofthehouse?Explainwhyorwhynot.6.Doyoufeeltheclient’sparents/guardian,aresupportiveoftheirson/daughterparticipatingintheBridgeDegreeprogram?Explain.7.Generally,howoftenwouldyousaythisclient’sparent’scontactyou?7a.Whenyou’recontactedbythisclient’sparents,whattypesofnegativeorpositivesituationsareyouaddressing?8.Doyoufeeltheclient’srightsandchoicesasanadultarebeingrespectedandsupportedbyhis/herparents/guardians?Pleasegiveexamples.9.Doestheclienthaveastrongsupportsystem?Statewhotheyareandhowtheysupporttheclient.
BridgetoIndependence
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Checktheboxforallthatapplytotheclient’shistoryof:_______________________________Causedpropertydamageincludingfires YES NOPhysicallythreatenedand/orattackedothers Verballythreatenedothers Self-injuriousbehavior Mistreatinganimals Consistentlyfollowsverbaldirections Elopement Lying Fabrication Inappropriatesexualbehavior Stealing Priorarrestorprobation Tobaccouse/abuse Marijuanause/abuse Druguse/abuse Alcoholuse/abuse Seizure(s) Currentgangbehavior,affiliationanddesires Incontinenceproblems Requiresattendantcare Resentmenttowardsparent(s) Ifyestoanyofthebehavioralandorself-careissues,pleaseexplainindetail.Includethemostrecentdate(s)oftheoccurrence(s)andseverity(useanothersheetformorewritingspace):
BridgetoIndependence
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Certification:Ihavecompletedthisapplicationtruthfully,andtothebestofmyknowledgeallinformationisaccurate.CaseManagementAgencyServiceCoordinator:__________________________________Date:_____________SignatureSubmissionofRegionalCenterReferralForm:Yourclient’scurrentAnnual/QuarterlyreportMUSTbesubmittedwiththisform.ThisreferralMUSTaccompanytheBridgeDegreeprogramapplicationwhenitisreceivedbytheprogram’sofficeforreview.Returnall3documentstoyourclientinanenvelopesealedasdirectedbelow.EnvelopeSealingInstructions:Oncecompleted,pleaseplacethisreferralinanenvelope,sealtheenvelopecompletely,writeyournameacrosstheoverlapoftheflap/envelopebody.Finally,placeagenerousamountofcleartapeoveryoursignature.
BridgetoIndependence
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AuthorizationtoReleaseInformation
Name(s)ofAgency,HighSchool,Professional,Medical(allthatapply)
Applicantname: DOB: Today’sDate:
BridgetoIndependenceatNichollsStateUniversityrequeststhefollowinginformationregardingtheaforementionedpersontoaidinprovidingqualityservices:Medicalinformation:
• DiagnosticInformation• CurrentMedications• TreatmentHistory• Assessments/Evaluations
PsychologicalInformation:• Diagnosticinformation• CurrentMedications• Treatmenthistory• Assessment/Evaluations
o IndividualEducationPlan(IEP) o IndividualTransitionPlanforEmployment
o EducationalAssessments/1508Evaluation
o SocialAssessmentInformation
o EmploymentAssessment(LouisianaRehab.Services)
o CaseManagementAgencyReports/Plan
o Other(describe): Bysigningbelow,IunderstandthatBridgetoIndependenceatNichollsStateUniversityshallshareinformationwiththereferringagencyandanyotheragenciesasitpertainstotheprogramservicesrenderedtotheaforementionedpersonandhis/herhealthandwelfare.IauthorizeBridgetoIndependencetorequestinformationfromthereferringagency,schoolandotherpertinenthealthcareprovidersthatisdeemedpertinenttoservicesprovided.IalsoauthorizethereleaseofinformationfromthereferringagencytoBridgetoIndependencetoaidinprovidingsuchservicesonlyuntilIcompletetheprogramorforthreeyearsfromsignaturedate(whichevercomesfirst).ApplicantSignature:_________________________________________Date:________________GuardianSignature:_________________________________________Date:________________BridgeStaffSignature:_______________________________________Date:________________
BridgetoIndependence
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ApplicantSkillInventoryApplicantName:____________________________________________________Personassistingorratingapplicant:_____________________________________Relationship:________________________________Date:_________________
UsethisrubrictoratetheapplicantwiththeattachedSkillInventory
WithNoAssistance
Applicantisabletoaccomplishthetaskwithoutassistance
LittleAssistance
Applicantrequires25-50%assistancetoaccomplishthetask
SignificantAssistance
Applicantrequires50-75%assistancetoaccomplishthetask
WithNoReminders
Applicantisabletoaccomplishthetaskwithoutreminders
FewReminders
Applicantisabletoaccomplishthetaskwithreminderson25-50%ofthesteps
ManyReminders
Applicantisabletoaccomplishthetaskwithreminderson50-75%ofthesteps
IsStilllearning
Applicantisabletoaccomplishthetaskwithreminderson50-75%ofthesteps
N/A
ThisparticulartaskisnotapplicabletothisApplicant
PlaceamarkintheappropriateboxindicatingtheLevelofAssistanceANDtheLevelof
Remindersneededtoaccomplishtheskill.Seeexampleonthenextpage.Pleasefollowtheexampleprovidedatthetopofthenextpage.
BridgetoIndependence
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Academics:General WithNoAssistance
LittleAssistance
SignificantAssistance
WithNoReminder
FewReminders
ManyReminders
IsStillLearning
N/A
Keepstrackofassignmentsandduedates
Bringspropersuppliestoclass Completesmultiplechoiceexams Completeswrittenexams Getsupinthemorningforschool
BridgetoIndependence
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WHATARETHISAPPLICANT’SNEEDS?
Whatarethestudent’sstrengthsandtheirareasofneed?Pleasedescribeindetailanypreviouslyusedsupports,accommodations,and/orbehavior/managementplan.Listanytypesofassistivetechnologyutilized.Ifyouneedmorespace,pleaseattachanadditionalpage.
BridgetoIndependence
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WHATWOULDANIDEALDAYBELIKEFORTHEAPPLICANT?
Whatwouldanidealdaybelikefortheapplicant?Pleaseincludeallcurrentpertinentrecreationalactivitiesaswellasareasofinterest.Ifyouneedmorespace,pleaseattachanadditionalpage.
BridgetoIndependence
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WHATISTHEAPPLICANT’SEDUCATIONALHISTORY?
Pleaselistanyeducationexperiencesthatwillgiveapictureofhowtheapplicantlearnsbest.Whereinschoolwastheapplicantmostsuccessful?Pleaseelaborateonstrengthsandareasforimprovement.
BridgetoIndependence
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GraffParentReadinessScale(GPRS)
Thisscalehelpsdeterminethefamilies’readinessforthestudentwithAutismSpectrumDisordertoattendapost-secondaryprogram.
Pleasecirclethefamily/guardian’sresponse.
1=Istronglyagree,2=Iagree,3=Ineitheragreenordisagree,4=Idisagree,and5=Istronglydisagree.
1.Iexpecttoknoweverythingmystudentsdoesattheuniversity.
StronglyAgree12345StronglyDisagree
2.Iexpectone-onesupportallday.
StronglyAgree12345StronglyDisagree
3.Iworryaboutmystudenttalkingtootherstudentsunsupervised.
StronglyAgree12345StronglyDisagree
4.Iworryaboutmystudentcrossingthestreet.
StronglyAgree12345StronglyDisagree
5.Ineedtoknowthehomeworkassignmentforeachclass.
StronglyAgree12345StronglyDisagree
6.Ineedtoknowthecalendarofactivitiesofferedtomystudent.
StronglyAgree12345StronglyDisagree
7.Iwouldliketospeakwithmystudent’ssupportstaff.
StronglyAgree12345StronglyDisagree
8.Iwouldliketoattendclassestoseemystudentinteractwithothers.
StronglyAgree12345StronglyDisagree
9.Itrustmystudent’sjudgment.
StronglyAgree12345StronglyDisagree
10.Itrustmystudent’sabilitytohandlesmallsumsofmoney.
StronglyAgree12345StronglyDisagree
11.Iknowmystudent,withsupport,willdevelopfriendships.
StronglyAgree12345StronglyDisagree
BridgetoIndependence
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GraffParentReadinessScale(GPRS)Continued
12.Iknowmystudent,withsupport,willtrynewopportunities.
StronglyAgree12345StronglyDisagree
13.Mystudenthastheabilitytohandlefrustration.
StronglyAgree12345StronglyDisagree
14.Mystudenthastheabilitytoseekassistance.
StronglyAgree12345StronglyDisagree
15.Often,Iamincontactwithmystudentsmorethan3timesaday.
StronglyAgree12345StronglyDisagree
16.Often,Iamtellingmystudentwhattodoandsay.
StronglyAgree12345StronglyDisagree
17.Icheckuponmystudent.
StronglyAgree12345StronglyDisagree
18.Ichecktoseeifmystudenthasthecorrectfacts.
StronglyAgree12345StronglyDisagree
19.Ibelieve,Iknowwhatisbestformystudent.
StronglyAgree12345StronglyDisagree
20.Ibelieveapostsecondaryeducationisimportantformystudent.
StronglyAgree12345StronglyDisagree
21.Ifeelthatmystudentknowswhatisbestforhimorherself.
StronglyAgree12345StronglyDisagree
22.Ifeelthatmystudentwantstoattendtheuniversity.
StronglyAgree12345StronglyDisagree
23.Mystudentwillliveindependentofourfamilyaftergraduation.
StronglyAgree12345StronglyDisagree
24.Mystudentwillhavemeaningfulemploymentaftergraduation.
StronglyAgree12345StronglyDisagree
25.PersonCenteredPlanningwillhelpmystudentachievetheirgoals.
StronglyAgree12345StronglyDisagree
BridgetoIndependence
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ScopeofServices
TheBridgeProgramisdesignedtoaddresstheuniqueneedsofstudentswithAutismSpectrumDisorder
ACADEMICS
ParticipantsintheBridgeDiplomaprogramatNichollsStateUniversityareenrolledthroughthe
traditionaladmissionsprocessasarealldegreeseekingstudents.TheBridgeDegreeprogramprovides
academicsupportservices.
HEALTHSERVICES
BridgestudentshaveaccesstocampusStudentHealthCenterservices.Theseservicesareforimmediate
firstaid/onsetcareonly.Bridgestudentsneedtomakeothermedicalarrangementsforlongtermcare
issues.Likewise,counselingandpsychologicalservicesprovidedbytheStudentServicesarealsofor
immediateemergencyinterventionsonly.Studentswithpre-existing/ongoingconcernsshouldmakethe
necessaryarrangementsfortheseknownissues.Bridgedoesnotendorseanyphysicianorcounselor
andthereforedoesnotmakereferrals.AspartoftheCollegeofEducation,individualandgroup
counselingservicesmaybeavailabletoBridgestudents.Theseservicesareprovidedbygraduatelevel
counselingstudentssupervisedbyaPh.D.instructor.OnceagainBridgedoesnotendorsetheseservices
andparticipationisoptional.
CODEOFCONDUCT
AllBridgestudentswillbeexpectedtoabidebythestudentcodeofconductasoutlined,
http://www.nicholls.edu/sja/files/2015/06/Code-of-Student-Conduct-Handbook.pdf.Bridgestudents
willfollowpoliciesofthejudicialsystemandtherecommendationsoftheVicePresidentofStudent
AffairsaswellastheBridgeAccountabilityPolicy.Anyresultingdisciplinaryactionwillfollowin
accordancewithNichollsStateand/orBridgepolicies.Thesepoliciesincludepermanentortemporary
expulsionofastudent.Parents/guardianswillneedtoacknowledgethattheywillbeactivemembersin
holdingtheirstudentaccountablefortheiractions.
PARENTS/GUARDIANS
ParentalinvolvementiscrucialforstudentsuccessintheBridgeProgram.Parentswillbeincorporatedin
manyimportantdecisionsthattheirstudentmaymakethroughBridgeIndividualPlanningMeetings.
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However,theremaybetimesthatBridgeisboundbyconfidentialityorjudicialrulings,andmaybe
unabletoshareinformationaboutthestudentwithouthis/herpermission.TheBridgeProgramgoalis
tosupportstudentsinbecomingindependentadults,capableofself-advocacyandself-determination.
Parentsmaynotalwaysagreewiththedecisionsthattheirstudentsmake,butshouldmaintaina
positiveandopenrelationshipwithallparties.
________________________________________________________________________
Applicant’sNamePrinted Applicant’sSignature Date
___________________________
Parent/GuardianSignature