The IEP, 504 Plan/IAP, or documentation of disability is required. 

Behavioral Information

Communication Information

Medical Information

I give permission for Louisiana Rehabilitation Services, 950 N. 22nd Street, Baton Rouge, LA 70802, 225-295-8900 to release to Opportunity Now Youth Services, P.O. Box 792, La Place, LA 70068, 985-359-2858 Specific information: personal information Purpose: provide vocational rehabilitation services.

Parent/Guardian 1

List emergency contact if you're 18 and over.

Parent/Guardian 2 (optional)

OPPORTUNITY NOW CUSTOMER AGREEMENT

To ensure that we deliver the very best services to you, Opportunity Now requires that expectations from both parties are clearly understood. This agreement is a summary of the guidelines that are required from Opportunity Now as well as you to ensure adequate learning and work experience.

This document verifies the understanding of services to be provided. Opportunity Now agrees to provide:

• Outreach and marketing services to employers for the promotion of qualified individuals with
• Assistance in education on job readiness.
• Assistance in education in general life skills.
• Assistance with resume writing.
• Assistance with job interview preparation.
• Assistance with employment and/or post-secondary education exploration.
• A professional and positive learning atmosphere.

YOU agree to:

• Attend all learning sessions with a positive attitude.
• Participate in class discussions and complete assignments.
• Sign all required documents needed for daily reporting.
• Conduct yourself in a professional manner without causing learning disruptions for yourself or your
• Be open-minded and flexible.
• Follow instructions.
• Bring all necessary materials needed for instruction to class sessions.
• Inform Opportunity Now of any changes in your telephone, address, email, or any additional contact information.
• Complete all necessary surveys for program feedback.
• Apply all relevant materials learned to additional classes and/or work experiences.
• Report any compliments or complaints that cannot be resolved by Opportunity Now representatives to LRS at 225-342-3111 (Louisiana Consumers).
• If you don’t uphold these responsibilities listed above, Opportunity Now may reserve the right to

         terminate services.

*Please note that you represent Opportunity Now and your perspective school campus when attending work-based learning experiences and you are to conduct yourselves in a professional manner while doing so.

I agree to the above terms to make this partnership a success in pre-employment transitional services. My signature acknowledges that I have received Customer Orientation with Opportunity Now.

MEDIA RELEASE

This form ensures the agreement between you and Opportunity Now by specifying that activities you participate in may be filmed and your image can be used by Opportunity Now or by XP Synergy Companies for promotional use. By signing this release, you are giving Opportunity Now permission to use your image in our promotional products that may be posted on the Internet and on our social media sites. Please note that you hereby agree not to bring claim or action against XP Synergy Companies and its subsidiaries, or Opportunity Now, for using media devices that may contain your image for publicity and/or other advertising uses.

By signing this you are giving the Opportunity Now Program consent to use your image without any further consent.

STUDENT EXPOSURE CONSENT FORM

This form is used for parents to grant their children permission to go on all field trips and events sponsored by the Opportunity Now Program. By signing this form, you agree to let your child attend all student exposure and events the Opportunity Now Program attends through the months of

To attend all student exposures and events please fill in the form below. Without a permission slip, you cannot attend any student exposures or events sponsored by Opportunity Now.