Pre-ETS Summer Program Eligibility Form

Pre-ETS Summer Program Eligibility Form

For students, age 16 and older, with a disability. Applications must be received by June 1, 2026.
Please verify that you are human*
Fill out the form below so we can get to know you better and match you with the right opportunity. The Pre-ETS Summer Program is located at Compass Partners in Learning - 1925 Plaza Blvd, Rapid City, SD 57702. For any questions or assistance, please call 605-939-0696 or email projectsearch@bhssc.org.
Personal Information
Full Name*
Date of Birth*

MonthDayYear
Date you were born
Street Address*
City*
State*
ZIP*
City/State/ZIP
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
School Information
Case Manager Name
School
Case Manager Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager Email Address
example@example.com
Vocational Rehab Information
VR Counselor Name
VR Counselor Email Address
example@example.com
VR Counselor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Information
Parent/Guardian Full Name*
Relationship*
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address*
example@example.com
Select your preferred Pre-ETS Summer Transition week.*

Week 1 – June 15–19 (Rapid City, 9 a.m.–2 p.m.)Week 2 – June 22–26 (Rapid City, 9 a.m.–2 p.m.)
Agreement

I release permission for Black Hills Special Services Cooperative to receive information from my Case Manager/VR Counselor including my IEP (Individual Education Plan) and MDAT. I agree to follow the organization’s policies and respect the values of the community I serve.
Participant Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

PLEASE SELECT ONE*

The State of South Dakota, Department of Human Services created this media.The State of South Dakota, Department of Human Services received this media from me.
I hereby grant the State of South Dakota’s Department of Human Services (hereafter “the Department”),permission and consent to record my image and to use and publish my name, photograph, and/or video of myimage for use in the Department’s videos, printed publications, websites, social media, or any other venue ormedium, and to freely use such information and images as the Department may elect. I understand and agree thatthese recordings of my image are the exclusive property of the Department.
I hereby grant the State of South Dakota’s Department of Human Services (hereafter “the Department”), permission and consent to use and publish my name, and the photograph, and/or video of my image which I have submitted for use in the Department’s videos, printed publications, websites, social media, or any other venue or medium, and to freely use such information and images as the Department may elect. I understand that ownership of this media is retained by me, but I am allowing the Department to use this media at no charge. Brief description of image(s) submitted to the Department:
Brief description of image(s) submitted to the Department
I hereby hold harmless and indemnify the State of South Dakota, the Department, its officers, agents and employees, from and against any and all actions, suits, damages and liability or other proceedings which may arise as the result of or in connection to the use of said information, photographs, videos, or images; and waive any claims which may arise. I have read and understood the provisions of this agreement, and voluntarily agree to all the terms herein.
Print Name*
Date*

MonthDayYear
Date
Participant Signature*

Clear
Telephone Number*
Format: (000) 000-0000.
Parent/Guardian Name (if individual is under the age of 18 or is under Guardianship):
Date*

MonthDayYear
Date
Print Name*
Parent/Guardian Signature*

Clear
Telephone Number*
Format: (000) 000-0000.

Media Release Form
Address: 2885 Dickson Drive, PO Box 218 Sturgis SD, 57785 Phone: (605) 347-4467

I hereby grant to BHSSC – Black Hills Special Services Cooperative (hereafter referred to as BHSSC) permission and consent to publish my name and photograph (and by video photography) my image for use in BHSSC’s videos, printed publications, websites, and social media, and to freely use such images in the exhibition, advertising, editorial use and publicizing thereof as BHSSC, its assigns, successors and licensees may elect. I acknowledge that since my participation in videos, print publications, websites, and social media produced by BHSSC is voluntary, I will receive no financial compensation. I further agree that my participation in any videos, print publications, websites, and social media produced by BHSSC confers upon me no rights of ownership whatsoever. I also release BHSSC, its contractors, and its employees from any and all liability for any claims by me or any third party in connection with my participation.

Parent/Guardian Signature (if subject is under the age of 18):
Print Name*
Type Name
Date*

MonthDayYear
Date
Participant Signature*

Clear
Parent/Guardian Signature (if subject is under the age of 18):*

Clear
Contact Info.*
Preferred method of contact e.g. email and/or phone number
Sender Name
Should be Empty: