Client Application Name of individual (required) Address of individual: Street: City: State: Zip: Phone no. of individual: Parent/guardian name: Parent/guardian phone: Parent/guardian email: From which county is your funding source? Number of days per week you would like to attend: Is transportation needed? ---YesNo SC's or SSA's name: Diagnosis: Date of Birth: Is adaptive equipment used throughout his/her day? ---YesNo [recaptcha] Δ