WFD Application

Select Program You Are Applying For:
*Pre-Requisite Course / may be taken as a stand alone course
Select What Semester You Are Interested In:*
Name (Last, First)*
Address
Street Address City State / Province / Region ZIP / Postal Code
Email Address*
Enter Email Confirm Email
Telephone*
Date of Birth*
Date Format: MM slash DD slash YYYY
Last Four Digits of your Social Security Number*:
*To be used for NYS paperwork only if you are admitted into the program
Vision Loss Diagnosis:*
Please state visual acuity if known:
If disability is physical, please state percentage of disability if know:
Are you able to work?*
If NO, please explain and/or provide documentation:
Has a doctor put any restrictions on you regarding employment?*
If YES , please explain further:
How did you hear about our program?

Personal Information Section
Education & Training:
High School Name, City & State
Dates Attended: High School
Type of Diploma
College/University Name, City and State
Dates Attended: College/University
Degree: College/University
Vocational Training/Program, City, State
Please let us know any other educational programs you have attended.
Dates Attended: Other Training
Degree: Other Training
If fluent in a foreign language(s), please list

Employment Experience

Please list your most recent job history. Start with your present status and include U.S. military service.
EMPLOYMENT EXPERIENCE: Please list your recent job history. Start with your present status and note any periods in which you were not employed. Include U.S. military service, summer/part-time jobs, and cooperative education assignments.
Employment Experience 1:
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Job Title:
Start Date (month/year)
End Date (month/year)
Rate of Pay
Job Description
Reason for leaving
May we contact this employer?
Employer Phone Number
Employment Experience 2:
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Job Title:
Start Date (month/year)
End Date (month/year)
Rate of Pay
Job Description
Reason for leaving
May we contact this employer?
Employer Phone Number
Employment Experience 3:
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Job Title:
Start Date (month/year)
End Date (month/year)
Rate of Pay
Job Description
Reason for leaving
May we contact this employer?
Employer Phone Number
Have you ever been terminated or asked to resign from any position?
(NOTE: this will not automatically disqualify you from consideration)
If yes, Please explain

Technology
Personal Goals:
Please tell us about your interests and your goals related to this program:
If possible please locate at least four jobs in your local area that are of interest to you. After listing those jobs below, in a few sentences, describe why these jobs interest you.
What is the average pay range for these jobs?
What are the major responsibilities for your top job of interest?
Additional Information: Open Case with State Vocational Agency
Name of Vocational Agency
Counselor Name:
Agency Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Counselor Phone
Counselor Email
Have you ever been convicted of a felony or misdemeanor?
(NOTE: this will not automatically disqualify you from consideration)
If Yes, provide details:
Please list the names and contact information for TWO emergency contacts: * Other than yourself
Emergency Contact ONE:
First Last
Relationship:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Emergency Contact TWO:
First Last
Relationship:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email

Consent and Signature:
PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN. BY SIGNING THIS STATEMENT YOU WILL ACKNOWLEDGE AGREEMENT.
I hereby affirm that the following information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration and may be considered justification for dismissal if discovered at a later date.

I understand that application to the program and providing supporting documents as part of my application is not a guarantee of admission to the program. I understand that my participation in the program may be terminated, with or without cause at any time at the discretion of either the director or myself.

I authorize persons, schools, and my current employer (if applicable), and previous employers and organizations named in this application (and accompanying resume, if any) to provide relevant information concerning me.
Consent*
- Yes, I agree
Name*
First Last
Date:*
Thank you! Thank you for your interest in the National Statler Center. Upon receipt of your application, you will be contacted for an admissions interview. If you have any questions about this form, or anything else about the program, please feel free to contact me. We look forward to speaking with you soon. Sincerely, Karla D. Manzella Coordinator of Admissions (716) 888.4526: kmanzella@statlercenter.org 1170 Main Street, Buffalo, N.Y. 14209 (application may also be found online at www.statlercenter.org)
APPLICATION REQUIREMENTS: 1. High School/GED/TASC diploma – copy of diploma and transcript 2. Open case with Commission for the Blind or Vocational Rehabilitation service provider ADDITIONAL ITEMS REQUESTED 3. Recommend the sharing of an ISP regarding employment goals and/or if applicable, recent 504 or IEP plan to assist staff with instructional supports 4. The Statler Center program seeks motivated applicants who have actively worked toward an employment outcome and pursued vocational development by engaging in activities such as (but not limited to) placement, job readiness, job clubs or education, and those who have an “everyday use of technology”. 5. Admissions Interview 6. Keyboard Assessment (20 word per minute threshold required) 7. Two reference (personal/non-family or professional) letters 8. *Distance Learning applicants must complete an on-line exercise

VIA WFD Training Programs Application-2020

Vocational Training Application

Step 1 of 6

Personal Information Section

Education & Training:

Education and Training Section

Assistive Technology Information

Employment Experience

EMPLOYMENT EXPERIENCE: Please list your recent job history. Start with your present status and note any periods in which you were not employed. Include U.S. military service, summer/part-time jobs, and cooperative education assignments.

Employment Experience 1:

Employment Experience 2:

Employment Experience 3:

Technology

Personal Goals:

Additional Information: Open Case with State Vocational Agency

Please list the names and contact information for TWO emergency contacts: * Other than yourself

Consent and Signature:

PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN. BY SIGNING THIS STATEMENT YOU WILL ACKNOWLEDGE AGREEMENT.