1 maguire rd. lexington, ma 02421 phone: (781) 860-1900 ......1 maguire rd. lexington, ma 02421...

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

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MGH Aspire Works Internship Application (New Participants) 18 and older

MGH Aspire Works Internship Application (18 and older)Program Interest Sheet (separate document)$75 non-refundable application fee for NEW MGH Aspire applicants.Most recent Neuropsychological or Psychological EvaluationMost recent copy of your resume (if you have one)Supplemental Info and Letter of Support Form mailed/emailed directly to the program 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:

APPLICANT INFORMATION

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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CAREER AND INTERESTS INVENTORY

PERSONAL INFORMATION What do you consider to be your greatest strengths?

Why are you interested in the Aspire Works program?

What are your personal interests and hobbies?

TRANSPORTATION

If Other, please describe (e.g., the RIDE):

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

1.

2.

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:

Highlight any transportation you expect to use to attend programming:

Use CRTL+Shift to highlight more than one option if filling out digitally, otherwise circle.

If Other, please describe (e.g., the RIDE):

Participant Name _____________________________________________________________ DOB___________________

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OtherList any scholastic honors you have received:

List any technical licenses or certifications you have obtained:

EMPLOYMENT OR VOLUNTEER HISTORY Most Recent Organization

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

Organization:


Current Full-Time Part-Time Location:


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 2School name:

End (m/y):

Location:

Graduation (or expected) Year:

Currently Attending

Start (m/y):

Part-Time Full-Time

Degree Earned:

Location:


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

Organization: Current Full-Time Part-Time Location:

Organization: Current Full-Time Part-Time Location:

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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.

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Company:

Email:

City: State: Zip Code:

Phone: Fax:

Professional who interacts with applicant outside of school or work (e.g. psychologist, psychiatrist, or social worker)

First: Role:

Company:

Email: City: State: Zip Code:

Phone: Fax:

Last:

Former Supervisor (if applicable)

First: Last: Role: signed release included


CONTACTS

Reference Type:

Additional Reference

Ext:

How long have you known this reference?

How long have you known this reference?


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.

Ext:

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.

Agency:

Email:

City: State: Zip Code:

Phone: Fax: How long has the applicant been seeing this professional? How frequently does the applicant see this provider?

First: Last: Role:


Agency Type:

Ext:

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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 ......1 maguire rd. lexington, ma 02421...

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