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]