MassAbility Pre-ETS Family/Emergency Contact

Student Name

SSN (if required)

Primary Language

D.O.B.

Gender

Race

Ethnicity

Address

Phone

Format: (000) 000-0000.

Email

example@example.com

Disability Documentation Type

Disability Diagnosis

Functional Limitations

Medications:

Allergies:

1.Name

Relationship

Mailing Address

Phone Number:

Format: (000) 000-0000.

Email

example@example.com

School Name

Grade

School Contact Name

Contact Phone

Expected exit date

Relationship with person at school

Contact Email:

example@example.com

Services Requested

I am requesting Pre-Employment Transition Services based upon the criteria that I am a student witha disability. I understand I will need to meet with a Pre-ETS Provider and develop a service plan thatwill be approved by MassAbility before I start receiving services. I understand that, as a recipient ofservices from MassAbility, I have the right to seek advocacy services from the Client AssistanceProgram (CAP) at (800)-322-2020 or www.mass.gov/mod/cap.

For the specific purpose of participation in Pre-Employment Transition Services, I grant permission forthe service provider to exchange information with the schools, authorized personnel, and MassAbilityto verify services were provided to me.

Student Signature

Date: ** if student is under 18 or has a legal guardian, their signature is required

Date

Parent Guardian Name

Parent/Guardian

Date

MassAbility Pre-Employment Transition Services Referral and Consent Form

Family/Emergency Contact

School Information

Consent for Service