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