Contact
LaKiesha LondonInterim Director/InstructorProgram for Successful Employment225-216-8281 pse@mybrcc.edu
First Name
Middle Initial (If you have no middle name put "N/A")
Last Name
Suffix
Semester Applying For: Fall 2024 Spring 2025
Gender Female Male
Date of Birth
Ethnicity: African American White Asian Native American Hispanic Other
If other was selected, please include here.
Please select Exceptionality or Disability (if more than one select all that apply.)The Program for Successful Employment (PSE) is a two-year vocational training program for adults with autism and/or other cognitive disabilities. This field is Autism/ Autism Spectrum Disability (ASD) Intellectual and Developmental Disability (IDD) Cerebral Palsy Down Syndrome Mental Health Disorder Other
Applicant's Current Physical Address
Current City
Current State
Current Zip
Applicant's Primary Phone Number
Applicant's Cell Phone Number
Applicant's Email Address (if no email, please put N/A)
Parent(s) or Guardian(s) Information
Contact First Name:
Contact Last Name:
Relationship to Applicant
Contact Phone Number
Alternate Phone Number
Contact Email address
This person can be contacted in regards to my application. Yes No
Education History
Name and location of current or last high school attended?
If currently enrolled, list current grade and date of anticipated completion. (Ex:12th, May 2020)
Did you complete High School with a Diploma HiSet or GED Certificate of Achievement Currently enrolled in high school
If yes to completion of high school, what year did you graduate?
Did you have an IEP ( Individual Education Plan) or 504 plan while in school? Yes No
College or Vocational Programs
Have you ever taken any college courses? Yes No
Name of College or Vocational School
Year(s) attended?
How many Credits earned?
Have you used assistive technology? Yes No
If yes, please explain the assistive technology you used.
Applicant Questionnaire
Why do you want to participate in the Program for Successful Employment at BRCC?
Do you currently have a paid or volunteer job? Yes No
Do you have a driver's license? Yes No
How will you get to BRCC and work? (Check all that applies) Parent City Bus Car Cats on Demand Other
If other, please indicate.
To be eligible to join a PSE cohort, the applicant must:
Do you meet the above requirements? Yes No Most of the requirements
If accepted, I acknowledge part of my vocational training will include participating in an unpaid externship. I agree to participate. Yes No
If accepted, I agree to participate in one benefits counseling session with a benefits counselor to discuss how working will/could possibly affect any government benefits I qualify for. Yes No Not Applicable- I do not receive benefits.
If accepted, I agree to follow the rules established by PSE. Yes No
If accepted, I acknowledge that funding to cover expenses must be paid prior to my first day of class. Yes No
In signing this application and acknowledging below, I acknowledge my answers are true to the best of my knowledge. I also agree to waive my right to confidentiality and authorize communication between the LEA (Local Education Authority) and PSE, in support of my application and enrollment of this program.
Please electronically Sign and date below.
Applicant Signature