1 maguire rd. lexington, ma 02421 phone: (781) 860-1900 fax: … · 2020-05-08 · 1 maguire rd....

1 Maguire Rd. Lexington, MA 02421 Phone: (781) 860-1900 Fax: (781) 860-1920 www.mghaspire.org

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MGH Aspire Works General Application 18 and older

MGH Aspire Works General Application (18 and older)Most recent copy of your resume (if you have one)Releases of Information (as applicable)Medical Record Number (MRN): Please see instructions below on how to get your MRN: Applicants must register with the Massachusetts General Hospital Registration & Referral Center. Please call the Center at 781-960-1203 to register and obtain a Medical Record Number (MRN).

Please Submit Your Application and Payment via: EMAIL PHONE

FAX MAIL

MGH Aspire accepts checks payable to MGH Aspire and sent to the address above or a credit card over the phone at 781-860-1900.

You will receive a confirmation email within 5 business days of MGH Aspire receiving your form. Applications are accepted on a rolling basis until programs are full. Candidates will be scheduled for an interview session at our Lexington office upon receipt of the complete application packet.

Please contact us at 781-860-1900 or email us at [email protected] if you have any questions.

Copies of staff background check procedures, healthcare and discipline policies are available upon request. .

Financial assistance is awarded based on financial need and fund availability. The financial aid application can be downloaded from our website.

Thank you for applying to the MGH Aspire program!

[email protected] 781-860-1900781-860-1920MGH Aspire1 Maguire Road

Lexington, Massachusetts 02421

Thank you for your interest in MGH Aspire programs. Please be sure to save this PDF file to your desktop/laptop computer and then open in Adobe Acrobat Reader. You may either enter your responses directly onto this form or you may handwrite responses on the printed form. A complete application includes:

mailto:[email protected]

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1 Maguire Road, Lexington, MA 02421 | Tel 781-860-1900 | Fax 781-860-1920 | www.mghaspire.org

Please provide the diagnoses received, for example, Asperger’s Syndrome, ASD, PDD-NOS, NLD, ADHD, or other:

Are you currently taking any prescription and/or nonprescription medication? Please list: Yes No

Have you ever been hospitalized (medical or psychological)? If yes, please describe reason and date(s):

Are there any physical, mental or psychological conditions requiring medication, treatment, or restrictions while in programming? If yes, please explain:

Yes No

Chronic Health Conditions (e.g., asthma, diabetes, seizures)

Allergies Special Diet Do you have any of the following? If yes, please explain:

Please describe your endurance for physical activities (walking/running/hiking/swimming):

Same Address as Applicant Email:

Office Phone:

Last: Relationship:

Ext:

FAMILY CONTACT INFORMATION (OPTIONAL)

Preferred Contact Method:First: Family Contact 1

Family Contact 2 Communicate with this person about:

signed release included

signed release icludedScheduling Payment/Aid Program Staff Communication

City:

DOB:

Race:

State:

Age: MGH MRN:Gender Identity:

Ethnicity:

Pronouns:

How did you hear about us?

Primary Language:

Country:

Cell:

Get Aspire Wire Newsletter

Email:

Home Ph: Preferred Contact Method:

Same Address as Applicant Email:

Office Phone:

Last: Relationship:

Ext:

Preferred Contact Method:

First:

Communicate with this person about: Scheduling Payment/Aid Program Staff Communication

First: Last: Office: Cell: Ext: Type:Role:

EMERGENCY CONTACT INFORMATION

First: Last: Cell: Office: Ext: Role: Type:

MEDICAL INFORMATION

Last: First:

Home Address:

Preferred/Nickname:

Zip:In the box to the right, highlight (CTRL+shift) or hand circle any option that describes your Living Situation:

APPLICANT INFORMATION

List at least one contact that could provide transportation home if necessary:

Home Phone:Cell Phone:

Home Phone:Cell Phone:

Physician Phone: Physician First Name: Physician Last Name:

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What do you consider to be your greatest strengths? GOALS

What goals would you like to work toward with the support of a career counselor (max 3)? Examples include: improving interview skills, learn how to do a job search, learn and practice how to network, etc.)

1.

2.

3.

What steps have you already taken toward your goals?

1.

2.

3.

What are some barriers you have encountered or could encounter when working toward your goals?

What will be different in your life/career once you've improved your skills and reached your goals?

Is there any additional information that may help your career counselor to know how to support you?

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CAREER AND INTERESTS INVENTORY Please review the general list of careers and job skills below. Place a check mark next to those that are of interest to you. If you think you might be interested in a career or job related skill but need more information, highlight or circle the skill.

Career Areas Job Related Skills Accounting/Finance Accounting Art Analyze Data Automotive Answer phones and great customer service Business Create and run database reports Communications/Marketing Customer Service Computers (Coding or Fixing) Data entry Development/Fundraising Drive a van and deliver products

Engineering Familiarity with programming languages (e.g., SQL, Java, CII, ASP, .NET, XML)

Healthcare (administrative) Lift and move up to 50 lbs. History Maintain warehouse inventory Information Systems (IS) Perform basic bookkeeping Legal Research

Museums Working knowledge of Microsoft Word, Access, PowerPoint and Excel

Office Administration Working knowledge of Social Media systems Science Other:

Participant Name _____________________________________________________________ DOB___________________


CAREER AND SUPPORT EXPERIENCE I am currently looking for (Check all that apply) Part-Time Full-Time More education Internship

Did you leave your last job voluntarily?

Have you worked with a job coach or supported employment program before?

When?

Did you find it helpful?

What were your responsibilities?

Yes No

Yes No

Yes No

Yes No

Not applicable

Do you have job experience?

OtherList any scholastic honors you have received:

List any technical licenses or certifications you have obtained:

EDUCATION INFORMATION High School

College/University 1

School name: No High School GED Graduation (or expected) Year:

School name:

Start (m/y): End (m/y): Graduation (or expected) Year:

Currently Attending Full-Time Part-Time

Degree Earned:

College/University 2 School name:

End (m/y):

Location:

Graduation (or expected) Year:

Currently Attending

Start (m/y):

Part-Time Full-Time

Degree Earned:

Location:

EMPLOYMENT OR VOLUNTEER HISTORY Most Recent Organization

Start (m/y): End (m/y): Description of Duties:

Organization: Current Full-Time Part-Time Location:

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Please include any information that is not already provided on an attached resume.

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Reference InformationFirst: Last: Role: Reference Type:

FAMILY SUPPLEMENTAL INFORMATION (OPTIONAL) What are the applicant's greatest strengths and skills?

What are the applicant's challenges? Is the applicant self-aware of these challenges?

Please list any special considerations MGH Aspire should be aware of (sensory issues, personal habits, triggers, calming strategies, etc.):

Please list 2 goals that you would like the applicant to achieve in this program

1.

2.

Please share any other information or concerns that you think would be helpful for MGH Aspire to know:


This Supplemental Information page provides the opportunity for a family member (e.g., parent/guardian) to provide additional information about the applicant.

SUBMIT

BILLING INFORMATION

Applicant:

Family:

Family:

Other:

First Last

Who? (e.g., District) Type

Other:

Who is responsible for payment and billing (must select at least one)? If Other, family must submit a letter of commitment including amount and contact information.

Click Submit to open your default email client. Click Save to save file to your computer.

To email: Please attach all required supporting documents (listed on the cover page) along with your completed application and send to [email protected]. If you cannot email, please provide a printed copy via fax, mail, or in-person delivery to the address below.

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Text Box

A note on insurance: MGH Aspire offers multidisciplinary interventions that do not fit standard medical procedure codes; therefore, our services are not reimbursable by medical insurers.

1 maguire rd. lexington, ma 02421 phone: (781) 860-1900 fax: … · 2020-05-08 · 1 maguire rd....

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