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Rise Application (Indian Hills Community College)

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www.indianhills.edu/rise
Living | Learning | Working
Academy
RISE
RISE Academy
Living | Learning| Working
1
RISE Academy/IHCC Packet Enclosures
RISE Academy Referral Guidelines and Expectations
RISE Academy Referral Process for IEP teams
Student Application Checklist
RISE Academy Referral Guidelines
PROGRAM DESCRIPTION
The RISE Academy is a 4+ program located in Centerville, IA at Indian Hills Community College. In conjunction with
the student’s high school, Indian Hills will continue to provide educational opportunities in the areas of living, learning
and working to fulfill unmet transition needs as identified in the student’s IEP (Individualized Education Plan). This is
a Monday-Thursday, one year, residential program that focuses on daily living, self-determination, interpersonal, and
employment skills. Students will have the opportunity to explore on and o campus employment. Students must be
in high school and have a current IEP with unmet transition needs.
APPLICATION DEADLINE
February 1
• Space is limited. Submitting a referral does not guarantee acceptance.
SCHEDULE
Fall Term
• Daily Living Skills I
• Self-Determination
and Interpersonal Skills I
• Employment Skills I
Winter Term
• Daily Living Skills II
• Self-Determination
and Interpersonal Skills II
• Employment Skills II
• Work Experience I (on-campus)
Spring Term
• Daily Living Skills III
• Self-Determination and
Interpersonal Skills III
• Employment Skills III
• Work Experience II (o-Campus)
CRITERIA FOR ENROLLMENT
• Enrolled in a high school special education program.
• Have unmet transition needs, as identified by the IEP team.
• Between the ages of 18 and 21.
• Show desire and motivation to cooperate and communicate with RISE sta.
• Have met high school graduation requirements.
SUGGESTED CRITERIA FOR ENROLLMENT
• Socially responsible behavior.
• Maintains district attendance standard of 95% or better.
• No inappropriate contact with students or sta. Follows the student code of conduct.
CONTACT TO SCHEDULE A VISIT TODAY!
Madison Rushing, RISE Coordinator | 800-726-2585, Ext. 1737 | madison.rushing@indianhills.edu
RISE Academy
Living | Learning| Working
2
Expectations
The following are expectations of RISE Academy students at Indian Hills Community College.
Students are expected to perform the following skills independently.
• Self-medicate, including taking correct dosages at correct times and refilling medication as needed.
Indian Hills Community College is not responsible for administering or monitoring medications.
• Take care of health and daily grooming including showering, using deodorant, brushing teeth, keeping
fingernails and hair neat, etc. with little guidance.
• Tidy dorm room weekly including picking up clothing, emptying trash, etc.
• Get up in the morning and arrive to class on time.
• Ability to follow a schedule
If students fail to follow the Indian Hills’ student code of conduct or the above expectations, RISE sta will arrange to
meet with the IEP team to discuss more appropriate transition options. Indian Hills Community College and the RISE
Academy program reserve the right to end services at any given time.
The housing contract is for the academic school year. Please read the dorm contract for rules regarding moving out
early and breaking contract. Students are subject to the housing rules and regulations put into place by Indian Hills
Community College. RISE sta will be involved in disciplinary decisions. Students are subject to dismissal based on the
severity of the violation.
It is expected that RISE Academy students have the ability to live on campus with minimal supervision. If outside
Agency supports are required, this must be disclosed at the time of application. Outside living supports are not allowed
in the dorm setting. The RISE Academy supports gaining independent living skills. Guardianship/conservatorship must
also be disclosed prior to acceptance into the program.
The RISE Academy is NOT a behavior management program. The RISE Academy program will not follow a Behavior
Intervention Plan from high school or outside agencies.
The RISE Academy program is not attached to a degree awarding program. Students will not be awarded transferable
college credit.
I have read and understand the above terms. Yes
Student Signature Date
Parent/Guardian Signature Date
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RISE Academy
Living | Learning| Working
3
RISE Academy Referral Process
RISE Academy Procedures for IEP Teams
Identification of a potential RISE Academy candidate should take place, at a minimum, during the junior year. The
transition discussion should begin as early as age 14. Referral to the RISE Academy program is a team decision and not
an individual recommendation.
Referral Procedures
1. The IEP team should complete a reevaluation during the student’s senior year to determine if the student
continues to be eligible for special education services or not. If not, the student is exited and does not
qualify for 4+ services. If the student does remain eligible, then the team should identify the student’s needs,
specifically those needs within the IEP, and discuss the placement options to meet those needs.
2. It is suggested that the student visit the RISE Academy program before a referral is made. Contact Madison
Rushing to schedule a visit.
3. If the RISE Academy is determined as a viable option;
a. Complete the RISE Academy referral form and return to madison.rushing@indianhills.edu
b. Invite a RISE Academy Representative to the IEP stang. This stang should take place the final
semester before attending RISE Academy.
c. Submit RISE Academy packet by appropriate deadline.
IEP Procedures
1. Page “I” should include the following information;
a. Vocational Rehabilitation information
b. Recent goals in IEP
c. Any health issues
d. Any behavior issues
e. Plans for living and/or transportation
f. Other information that may be relevant, but not included in their IEP.
2. Page B should include the following information;
a. Post-Secondary expectation for living, learning and working
All steps must be completed and submitted before a student referral will be accepted. Send all referral information to
Madison Rushing, RISE Coordinator, by the following deadline.
• February 1
Indian Hills Community College
Attn: Madison Rushing
525 Grandview Avenue
Ottumwa, IA 52501
OR
madison.rushing@indianhills.edu
For questions contact your AEA Consultant or call the RISE oce at 1-800-726-2585 ext. 5226
RISE Academy
Living | Learning| Working
4
RISE Academy/IHCC Referral
To be completed by a special education teacher.
Student: Date:
DISTRICT INFORMATION
High School:
IEP Teacher:
Email:
Name of District Administrator:
Approving Referral: Date:
Is the student open enrolled from another school district? Yes No
If yes, which district?
If yes, name of District Administrator:
Approving Referral: Date:
ATTENDANCE & ACADEMIC HISTORY
Total Absences:
Senior Year:
(as of ) Junior Year: Sophomore Year:
Current Cumulative GPA:
Explanation of Excessive Absences or Tardiness:
VOCATIONAL REHABILITATION
Does the student have a file with Vocational Rehabilitation?
Yes No
RISE Academy
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IEP INFORMATION
Reevaluation Date:
Consultant:
IEP Goals:
Work Experience:
Transition Needs:
Accommodations: Please list all accommodations student is currently using:
The student is expected to be able to perform the following skills independently.
Please verify that this student has the following skills:
REQUIRED SKILLS
Medication YES NO
Take medication in correct dosages at correct time.
Refill medication as needed.
Independence
Student is able to live independently with minimal supervision.
PREFERRED SKILLS
Dorm/Independent Living
Take care of health and grooming daily. This includes showering, using deodorant,
brushing teeth, keeping fingernails and hair neat.
Keep dorm room tidy daily. This includes picking up clothes, emptying trash, cleaning kitchen,
bathroom & living areas.
RISE Academy
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Organizing Your Day YES NO
Get up on your own and arrive to class on time.
Being prepared by having your own safety/first aid kit.
Academically
Write down homework assignments and come to class prepared.
Organize your work. This includes knows what needs to be done, gets started independently
and has an organizational system.
Follow a schedule.
Assistive Technology (specify):
REFERRAL APPROVAL
I certify that my answers are true and complete to the best of my knowledge.
Teacher Signature:
Date:
Administration Signature: Date:
APPLICATION DEADLINE
RISE Academy applications must be received prior to the appropriate deadline listed on page three.
Return to: Indian Hills Community College
Madison Rushing
525 Grandview Ave
Ottumwa, Iowa 52501
It is the policy of Indian Hills Community College not to discriminate on the basis of race, color, national origin, sex, disability, age (employment), sexual orientation, gender identity, creed, religion, and
actual or potential parental, family, or marital status in its programs, activities, or employment practices as required by the Iowa Code §§216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964
(42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C §§ 1681 – 1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. §
794), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).
If you have questions or complaints related to compliance with this policy, please contact Director, Human Resources/Equity Coordinator (sta), 525 Grandview Ave, Ottumwa, IA 52501, 683-5108,
hrequity@indianhills.edu; Dean, Student Aairs (students), 683-5159, studentsequity@indianhills.edu; Dean, Learning Services (students with disabilities), 683-5174, learningservicesequity@indianhills.
edu; U.S. Department of Education, Citigroup Center, 500 W. Madison, Suite 1475, Chicago, IL 60661, phone number 312/730-1560, fax 312/730- 1576.
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RISE Academy
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Student Application Checklist
To be completed by the student.
The following information/steps should be completed by the prospective student.
RISE Academy Application
Photo/Video Release Form
Permission to Travel
Review and sign the RISE Academy Attendance Policy.
Review and sign the RISE Academy IHCC Student Conduct.
Review and sign the Student Disability Services Release of Confidential Information.
Note: If a student is unable to attend IHCC/RISE Academy, he/she must notify IHCC, RISE Academy, and his/her
high school.
Additional Information: RISE Academy students are still considered high school students and their diploma will be
held by the district until the student has exited from special education services.
It is the responsibility of the student to contact IHCC and RISE if their phone number, mailing address, and or
email address changes any time after application materials have been submitted. Contact RISE at 800.726.2585,
ext. 5226, for additional information.
RISE Academy
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8
RISE Academy Application
Program of Study:
STUDENT
Name:
Address:
City, State, Zip:
Phone: (home) (cell)
Date of Birth: SSN#:
Email:
Academic start year: Fall Winter Spring Summer
Gender: Male Female US Citizen: Yes No
Have you been convicted to a felony? Yes No
Do you have any behavior issues or a behavior goal listed on your IEP? Yes No
If yes, please explain:
To be completed by student. List 3 reasons why you would be a good candidate for the RISE Academy.
To be completed by parent or guardian. List 3 reasons why your student would be a good candidate for the RISE Academy.
List any volunteer or work experiences.
RISE Academy
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Required Skills:
1. Can you self-medicate, if necessary? Yes No
2. Can you refill medications as needed? Yes No
3. Can you live independently, with minimal supervision? Yes No
PARENT/GUARDIAN
Name:
Relationship:
Address:
City, State, Zip:
Phone: (home)  (cell)
Email:
PARENT/GUARDIAN
Name:
Relationship:
Address:
City, State, Zip:
Phone: (home)  (cell)
Email:
SPECIAL NEEDS/CONCERNS
I have completed this application to the best of my ability. I understand that any misleading information provided
may result in dismissal from the program.
Student Signature Date
Parent/Guardian Signature Date
RISE Academy
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10
Photo/Video Release Form
I give Indian Hills Community College permission to photograph and video
while participating in the RISE Academy. I understand that videos and photographs will be used for marketing purposes
to promote the program in a positive manner. Indian Hills Community College owns the rights to all photographs,
videos and marketing pieces.
Student Signature Date
Parent/Guardian Signature Date
Permission to Travel
I give permission to Indian Hills Community College to transport
or arrange for transportation with community transportation options.
Student Signature Date
Parent/Guardian Signature Date
RISE Academy
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11
RISE Academy Attendance Policy
• A total of three absences will be accepted during any given term (12-week period). Upon the fourth absence,
an IEP meeting will be held to decide what action will be taken.
• Tardiness will not be tolerated. Three individual tardies will count as one missed class. Three individually missed
classes will result in a day’s absence.
• RISE Academy students follow the IHCC scheduling, including weather delays or cancellations. If a student’s
family feels it is unsafe for him/her to travel, the student must notify all of the teachers of classes that will be
missed. The student is responsible to make up all missed work.
• RISE Academy is a closed campus program. The student’s family assumes all responsibility and liability when
the student is not in educational programming and if the student leaves the campus.
I HAVE READ AND UNDERSTAND THE ABOVE POLICY.
Student Signature Date
Parent/Guardian Signature Date
RISE Academy
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12
RISE Academy/IHCC Student Conduct
Student conduct rules are structured to provide respect and protection to the rights and welfare of all students.
The IHCC Board of Trustees has approved a policy that provides for the due process of individual students.
Policy for student conduct, suspension, and dismissal
I. Suspension shall be defined to mean exclusion of a student from classes and/or activities during part of a term,
but at no time more than twenty (20) school days.
II. Dismissal shall be defined to mean the exclusion of a student from classes and/or participation in school
activities for a period of time up to the end of the current term and the next term. If the student is dismissed,
the student may be re-admitted on terms and conditions stated in the dismissal.
III. Standards of student conduct, the violation of which may lead to suspension or dismissal, are:
A. Obstruction or disruption of the learning environment.
B. Obstruction or disruption of college students’ activities or events.
C. Conduct which threatens or endangers other persons or college property or which threatens
or endangers other property at college sponsored events.
D. Theft or damage to property owned by students, college employees or visitors on college property
or at college-sponsored events.
E. The unlawful entry into college-owned buildings or the unlawful use of college equipment or vehicles.
F. The illegal use, possession or distribution of controlled substances, as defined by the laws of the State
of Iowa, while on college property or at college-sponsored events.
G. The possession of firearms, dangerous weapons or explosives while on college property
or at college-sponsored events.
H. The habitual noncompliance with health or safety regulations established either by a municipality,
state, or federal government, or health or safety regulations established by the college and which the
students have been informed that such regulations must be followed.
The IEP team reserves the right to exit the student from special education services and the RISE Academy program,
if deemed appropriate, due to misconduct and/or failing to maintain attendance and/or educational standards.
I HAVE READ AND UNDERSTAND THE ABOVE POLICY.
Student Signature Date
Parent/Guardian Signature Date
REV. FALL 16
RISE Academy
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13
Release of Confidential Information Form 2017
IHCC SDS FORM 2
INDIAN HILLS COMMUNITY COLLEGE
Student Disability Services
Release of Confidential Information
Student’s Name: _______________________________________________
SSN # ________________________________ Birthdate: __________
Permission for IHCC Instructors/Professors & Appropriate Staff
I hereby give permission to the IHCC Student Disability Services Coordinators to
release confidential information from my file in order to set up classroom
accommodations and/or services connected to accessibility and my specific
disability. I understand that I must provide the required documentation of my
disability in order to receive accommodations and services.
__________________________________________ ________________
(Student’s Signature) (Date)
Permission for Family, Agencies, and Others
I hereby give permission to the IHCC Student Disability Services Coordinators to
release confidential information on my behalf to the following:
☐Parents/Guardians: __________________________________________
☐Vocational Rehabilitation Counselor: _____________________________
☐Job Corps: _________________________________________________
☐Other: _____________________________________________________
I understand that this authorization is in effect until I complete an updated form.
__________________________________________ ________________
(Student’s Signature) (Date)
RISE
Raise Individual Student Expectations
Madison Rushing
Coordinator, RISE Program
525 Grandview Ave
Ottumwa, IA 52501
800-726-2585, ext. 1737
RISE Classroom (641) 683-5226
madison.rushing@indianhills.edu
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