Funding for this program has been provided by The City of Houston Community Development Block Grant (CDBG) to provide vocational skills training to adults with Intellectual or Developmental Disability. To qualify for this program, participants MUST respond “YES” to ALL questions above.

Please select one (1) item from each section below and submit with application.

A. Proof of Residency The applicant MUST reside within the city limits of Houston.
Examples of acceptable documentation include:

• Current utility bill
• Pay stub (if address is printed on stub)
• Rent receipt (showing current address)
• Lease agreement
• Mortgage statement
• Section 8 award letter
• Homelessness determination

**Note: If applicant does not have any of the above, documentation from the parent/guardian listed on the application may be used if the applicant residing with that individual.

B. Proof of Diagnosis The applicant has an Intellectual/Development Disability and MUST provide a copy of diagnosis. Examples of acceptable documentation may include but not limited to:

• Psychological Evaluation form
• Determination of intellectual disability (DID) documentation
• Physician’s note
• IEP or ARD

**Note: Other acceptable documents are not exempt but on case-by-case basis

C. The applicant is at least 18 years of age or older. Must provide proof of age. Examples of acceptable documentation:

• Copy of Valid state ID
• Copy of Passport
• Copy of birth certificate
• Permanent resident card

D. The applicant MUST qualify for or receives Supplemental Security Income (SSI) and/or Medicaid Example of acceptable documentation:

• Current SSI award letter
• Copy of Medicaid card
• State Benefit card/form

**Note: other documentation may be accepted on a case-by-case basis

E. Must be eligible for employment in the U.S. and provide documentation. Examples can include:

• Must provide copy of social security card with work authorization.
• U.S. passport or U.S. passport card
• Permanent resident card or alien registration receipt card (INS Form I-551)
• Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
• Employment Authorization Document that contains a photograph (INS Form I- 766)
• Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
• Driver license or ID card issued by a state or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
• ID card issued by federal, state, or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
• School ID card with a photograph
• Voter registration card
• U.S. Military card or draft record
• Military dependent’s ID card
• U.S. Coast Guard Merchant Mariner Card
• Native American tribal document
• Driver license issued by a Canadian government authority

Issues with form: sbaron@heartprogram.org

Completing the application and the in-take form is not a guarantee of acceptance into the program. Upon successful completion of all necessary paperwork and presentation of the proper documentation, your application will be reviewed and an initial meeting will be scheduled to access the potential program participant. Please visit our frequently asked questions section to see if The H.E.A.R.T. Program is a good fit for your loved one. Review the purpose of the program, its requirements and what a participant can expect to experience as a trainee in The H.E.A.R.T. Program.

Valid State ID OR Driver’s License and Social Security Card MUST be provided. ALL documentation MUST be submitted with Application and Intake form for consideration - see bottom of this form.

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