New Online Application

1000 College Boulevard
Building 1, Room 4
Pensacola, FL 32504

Online Application

A completed application and appropriate documentation must be submitted. Incomplete applications will delay the review process. It is acceptable for the applicant to receive support in completing the application. All information will be kept confidential and will not be shared with any outside agency without written permission from the applicant/parent/guardian.

Our new online application process allows you to save and continue working on your application, upload documents, and submit once you're done. Don't hesitate to call the office at 850.484.1185, stop by, or email us at pals@arc-gateway.org with any questions you may have. We are here to help.

The application submission deadline is September 29, 2017. The Arc Gateway PALS classes begin January 2018.

Social Security Number

Permanent Address

Student receives support from: (Check all that apply)

Receiving services from the Agency for Persons with Disabilities (APD)

On the waiting list for services with APD

Whether receiving services or on the waitlist, who is your APD Coordinator?

Division of Vocational Rehabilitation

If yes, who is your VR Counselor?

Supplemental Security Income (SSI) and/or Social Security Disability Income (SSDI)

Primary Emergency Contact

Alternate Emergency Contact Person

Student 's Legal Rights

Name of court appointed legal guardian(s):

Include copy of court guardianship documentation

Program Qualification Information

Receiving services through the Agency for Persons with Disabilities (APD)

On the wait list for the Agency for Persons with Disabilities (APD)

Child of a veteran living at home in Florida

Student Eligibility Criteria

Students in The Arc Gateway PALS will be deemed eligible upon meeting the following criteria:

A. Have a documented intellectual or developmental disability (I/DD).
B. Have completed high school coursework and received a regular diploma, special diploma, GED, or certificate of completion.
C. Have a desire to continue education in a college setting.
D. Have exhibited a need and a desire for greater independence.
E. Able to be independent on a college campus.
F. Have had two paid or unpaid community work experiences (preferred).
G. Exhibit socially adaptive and responsible behavior when left unsupervised.
H. Able to communicate with others.
I. Meet one of the following age criteria:
1. Be at least 18 years old.
2. Be within 4 months of their 18th birthday.
J. Have satisfactory school attendance from previous schools.
K. Consent to being photographed, videotaped, interviewed and/or quoted in media and publications.
L. Have personal cell phone before entering the program (preferred).
M. Consent to participate in longitudinal research studies.
N. Must be determined eligible by at least one of the following

(please mark all that apply)

Receiving services from the Agency for Person with Disabilities (APD); or

On the Waiting List with Agency for Persons with Disabilities (APD)

Education Information

List schools attended in chronological order beginning with the most recent.

School Attended (Most current)

Classroom Setting (ESE Classes, Inclusion, Mainstream, etc.)

School Attended (Previous)

Classroom Setting (ESE Classes, Inclusion, Mainstream, etc.)

School Attended (Additional)

Classroom Setting (ESE Classes, Inclusion, Mainstream, etc.)

1. Do you have a high school diploma?

Do you have a Special Diploma?

Yes No Not Selected

Do you have a Certificate of Completion?

Yes No Not Selected

If no, anticipated graduation or completion of high school:

(month / year)

Please describe your academic strengths and weaknesses.

How do you think you learn best? (e.g.: small groups, extra time, etc.)

In the following areas, describe what skills you would like to learn: Independent Living

Social/recreational/leisure

What accommodations did you receive in educational settings?

What assistive technology have you used in educational settings?

Work/Volunteer History

List work and/or volunteer experiences in chronological order beginning with the most recent.

Name of Business (Most Current) & Supervisor

Job Responsibilities

Name of Business & Supervisor

Job Responsibilities

Name of Business & Supervisor

Job Responsibilities

Business/ Employer Supervisor

Job Responsibilities

What work experiences do you have an interest in or enjoy?

Transportation

As part of The Arc Gateway PALS, transportation will be provided to and from the college campus for people living in most areas of Escambia and Santa Rosa counties.

Do you require wheelchair accessible transportation?

Yes No Not Selected

If wheelchair accessible transportation is not available, are you able to transfer?

Yes No Not Selected

Do you have an alternate transportation plan to allow for recreational, social, and job opportunities occurring before 8:00am, after 3:00pm and on weekends?

Yes No Not Selected

List any limitations, support needs, or related issues impacting your transportation.

1. Give a brief description of your medical history, including disability diagnoses.

2. List any significant medical, psychiatric, behavioral, and/or physical conditions that may impact your participation in classroom, social, or recreational activities on campus, including allergies.

3. List any current medications you are taking. If you must take medications while on campus, you must be independent in self-administering the medications.

4. Provide any other medical information that you feel would be important regarding your participation in this program.

Student Questionnaire

1. Discuss any activities, hobbies, and/or groups (social, religious, volunteer, civic organizations) that you belong to or participate in.

a. I play the following sports:

b. I belong to the following clubs and/or organizations:

c. My other interests include:

2. Discuss two goals you have for the future.

3. What classes would you like to take while at college?

4. Are you now or have you ever been charged with or subject to a disciplinary action for misconduct at school?

Yes No Not Selected

If yes, please explain

5. Have you ever been convicted of a criminal offense or have charges pending of any criminal offense?

Yes No Not Selected

If yes, please explain

If you answered yes to questions 4 or 5, you may required to provide written documentation of the event. You may be required to provide the program with your documentation from your school administration or legal representation and copies of all official documentation explaining the final deposition go the proceedings.

Copy of Official Documentation explaining the final deposition

Required Documents

Please download all the forms from the links below and upload the completed forms as an attachment.
Personal Support Inventory
Student / Parent / Guardian Memorandum of Understanding
Research Consent Form
Personal Letter of Recommendation Form

Personal Support Inventory

Student / Parent / Guardian Memorandum of Understanding

Research Consent Form

Personal Letters of Recommendation

Copy of Social Security Card (Signed)

Copy of Most Recent Individual Education Plan (IEP)

Functional Behavior Assessment (If Applicable)

Psychological / Educational Assessment or Evaluation

Copies of High School Transcripts

Military Dependent Documentation (If Applicable)

DD214, Military Dependent ID Card

Personal Statement

In order to be sure that The Arc Gateway Program for Adult Learning and Support (PALS) at Pensacola State College is the best match for our applicants, we require, as part of the application process, that each student complete a personal statement. This will help PALS staff and committee members get to know you as a person, as well as tell us a little about your desires and goals.
In your Personal Statement, include information about:

1. Yourself (i.e.: family, friends, favorite pastimes, sports, school)
2. Your dreams for the future
3. Why you would like to become a PALS student
4. Any other details about yourself that will help you stand out as an applicant.

This can be written, videotaped, or recorded. There is no required length, but more is not necessarily better. Be creative.
Note: Originals will not be returned.

Personal Statement

Personal Recommendation Forms

Please download and send this form to TWO Referrals and request them to email the completed forms to the following email:
PALS@Arc-Gateway.org
or mail to:
The ARC Gateway PALS
1000 College Blvd., Building 1, Room 4
Pensacola, FL 32504

Personal Letter of Recommendation Form

Workplace Recommendation Form

Please download and send this form from the link below and request your employer to email the completed form to the following email:
PALS@Arc-Gateway.org
or mail to:
The ARC Gateway PALS
1000 College Blvd., Building 1, Room 4
Pensacola, FL 32504

Workplace Letter of Recommendation Form

Release and Exchange of Information Form

Please download, fill out and attach this form:

Release and Exchange of Information Form

The Arc Gateway, Inc. will treat and regard all written documentation obtained to verify a disability and plan for appropriate services as confidential. However, it will be necessary for The Arc Gateway PALS personnel to exchange information about you with college faculty and staff in order to provide appropriate educational opportunities and experiences on and off campus. This exchange will occur only with your written permission, as given by signing below, and with the understanding that only information necessary for the purposes of accommodation and academic progress will be communicated.

Release of Information Form

I give permission to exchange information about me to the following offices/individuals.

The Arc Gateway, Inc.

Agency for Persons with Disabilities

Pensacola State College

Division of Vocational Rehabilitation

School District (please enter below)

Other (please enter below)

If school district, please specify county and state

If other, please specify

I understand this application is for admission to The Arc Gateway Program for Adult Learning and Support (PALS) at Pensacola State College and is only valid for the term indicated. I agree to the release of any transcripts, records, student records, and test scores to the designated PALS staff. I certify that information given in this application and all required documentation provided is complete and accurate. I also understand that to make false or fraudulent statements in this application may result in denial of admission. If admitted to the PALS program, I agree to abide by the policies, rules, and regulations of The Arc Gateway PALS and Pensacola State College. I will notify PALS staff of any changes to the information in my application as soon as possible.

I have completed all required application requirements and have included them in the application packet.

Enter the above code

Required

Online Application

Student Information

Permanent Address

Student receives support from: (Check all that apply)

Primary Emergency Contact

Alternate Emergency Contact Person

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Student Eligibility Criteria

Education Information

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Work/Volunteer History

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Transportation

Medical History

Student Questionnaire

1. Discuss any activities, hobbies, and/or groups (social, religious, volunteer, civic organizations) that you belong to or participate in.

2. Discuss two goals you have for the future.

3. What classes would you like to take while at college?

Required Documents

Personal Statement

Personal Recommendation Forms

Workplace Recommendation Form

Release and Exchange of Information Form