Adult Program Application

Adult Program Application

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email

Phone

Home

Phone

Work

Phone

Cell

DOB*

Date of Birth

Social Security Number *

xxx-xx-xxxx

Medicaid Number

Name of Parent or Guardian*

Employer

Diagnosis/Diagnoses*

High School Attended*

High School Graduation Year*

Has he/she attended a day program in the past? *

Name of the Day Program

Reason for leaving the program

What kind of waiver does he/she have?*

Name and Phone Number of Support Coordinator (if applicable)

Is he/she interested in employment? *

Name and relationship of others who live in the home. *

Name, Relationship, and Phone Number of Emergency Contacts*

This information is confidential and will not be released without your consent. Please click this box indicating that all information is accurate. *

All information submitted in this form is accurate.