Disability Support Services
SEED Application
Application Packet should include:
1. Completed application along with essay questions
2. High school evaluation report and/or IEP; other documents verifying disability
3. Two written recommendations for the program from [High school personnel, mentor, OVR
counselor, community provider, etc.]. Please no recommendations from parents/guardians.
Please Print
Name: L# (if applicable):
Address: City:
State: ZIP Code: Phone: (cell) (alternate)
Email Address: Career Path:
Name of High School:
Parent/Guardian Name:
Parent/Guardian Phone: (cell) (alternate)
Parent/Guardian Email:
Structure of Your Classes in High School (Check all that apply)
10 or less students in class
11-20 students in class
Over 20 students in class
Social skills/Strategies
Learning Support
General Education
Individual Instruction
Resource Room
1:1 Aid/Support
o All day
o Half day
o As needed
1:1 Aid/Support
o Behavioral
o Academic
o Both
Disability Support Services
Workshop Experience
Have you ever been employed/worked a paying job? Yes No
Have you ever done volunteer work? Yes No
Will you complete your required programming in K-12 or earn a GED by June 2020? Yes No
If NO, will you receive a certificate of attendance by June 2020? Yes No
Stress What situations makes you feel stressed? (Check all that apply)
Talk with others
Advocating needs
Social events
Being late
Loud noises/sounds
Planning transportation
Organizing schoolwork
Change in routine
Getting work done on time
Things not in order/quarterly
Working in groups
Taking criticism
Parental involvement
Not enough sleep
Meeting new people
Unclear directions
Social Interaction (Check all that apply)
Can start a conversation
Avoid talking with others
Make friends easily
Prefer to be by myself
Have five or more friends
Would like to be more social
Enjoy going to events with others
Prefer to stay home
Like to try new things
Have no friends outside of school
Get along well with family
Maintain friendships easily
Enjoy talking with teachers
before and/or after class
Can end the conversation
Can maintain a conversation
Talk to teachers only when needed
I would like to have more friends
Prefer to do things with family
Have 1-2 friends
Enjoy meeting new people
Enjoy going to others’ homes
How did you learn about SEED?
Disability Services
Disability Support Services
I do the following to have fun: (Check all that apply)
Play on the computer
Outdoor activities
Watch sports
Go for a walk
Play sports
Surf the Internet
Watch movies
Do crafts
Watch TV
Ride bicycles/skateboard
Go out to eat
Hang out with friends
Go to concerts
Listen to music
I, the below signed, understand that if I am selected for the SEED Program, I am expected to participate fully in
the bridge program scheduled July at the Lehigh Carbon Community College campuses located in Schnecksville.
I further understand that I will be responsible for my own transportation to and from all SEED-related activities
and programming.
Signature Date (mm/dd/yyyy)
Educational Support Services
Please answer each of the following questions in essay format. Please see below for criteria used to evaluate
Using 200 words or less, type or print your response on a separate sheet(s) of paper, OR type on the computer
in the spaces provided in this document (text boxes are size-limited per answer), save and email.
Your responses will be evaluated to determine whether you will be recommended to advance in the selection
process. If selected, you will be contacted for a personal interview.
1. What is your career/academic goal?
2. What major event in your life demonstrates your commitment to achieving your goals? Talk about
something that required your persistence to complete.
3. How will this program support you in attaining this goal?
Educational Support Services
Directions for Response Section of SEED Application
Application responses can be typed into the boxes in this PDF form, saved and emailed back to
Otherwise, all Application responses must be legible and submitted on 8 1/2” by 11” paper, and either type
written (12 point and double spaced) or hand printed in ink on lined paper. Questions may be answered on the
same or multiple pages. Include your name on each page and include the question before each response.
Criteria for Evaluation
1. Goals and interests expressed are aligned with the objectives of the SEED Program.
2. Each essay responds to the related question, is focused and demonstrates the writer’s desire and
qualifications to move forward in the SEED selection process.
3. The writer supports his or her responses with examples or well-developed reasoning.
4. The writer organizes ideas.
5. Conventions of grammar, spelling and punctuation are demonstrated.
Completed application should be: hand deliver or mail to Michelle Mitchell, Educational Support Services,
SH 150, 4525 Education Park Drive, Schnecksville PA 18078; or e-mail to MMitchell@LCCC.edu
PERM24A-x (AC)