REACH Registration

Name of Participant (If you are signing up for more than one participant, please fill out a separate form for each participant) *

First NameLast Name

Date of Birth*

Date

Gender*

MaleFemale

Last Four of SSN (Waiver Recipient)*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County of Residence*

Are you a current client of Embracing Abilities?*

Funding Source*

Parent/Guardian/Self:*

First NameLast Name

Parent/Guardian/Self Phone Number*

Email*

example@example.com

Case Manager's Name*

First NameLast Name

Case Manager's Email*

Confirmation Emailexample@example.com

Select the WEST REACH Editions you would like to register for:

Cooking Class - Mondays 10-12pm (December 9, 16, 23, 30, January 6, 13)

Select the WEST REACH Special(s) you would like to register for:

Winter Special: Danville Drive Through Lights - December 17th 6-8pm

Select the NORTH LOCATION REACH Editions you would like to register for:

Cookie Decorating (All Ages) - Wednesday, December 13th, 2023 - 6:00-8:00 PM

WINTER CRAFT NIGHT | REACH SPECIAL - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.*

Consumer is appropriate for a 4 to 1 group setting ratio.Consumer would benefit from social interactions with peers.Consumer is able to hear, comprehend, and follow directions in order to complete the activity with minimal assistance.Consumer has basic fine motor skills to independently utilize art and craft supplies.I understand there is a $10 activity fee for this event.

COOKIE DECORATING | REACH SPECIAL - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.*

Consumer is appropriate for a 4 to 1 group setting ratio.Consumer is able to safely eat independently or with minimal assistance.Consumer would benefit from social interactions with peers.Consumer has basic fine motor skills to independently utilize art and craft supplies.I understand there is a $10 activity fee for this event.

POLAR EXPRESS | REACH SPECIAL - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.*

Consumer is appropriate for a 4 to 1 group setting ration.Consumer would benefit from social interactions with peers.Consumer enjoys movies and is able to attend in an appropriate manner.Consumer is able to tolerate a dark environment and occasional loud noises.Consumer is able to remain sitting for a movie.I understand there is a $10 activity fee for this event.

EA Rocks! Music Group - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.

Participant is appropriate for a 4:1 group setting ratio.Participant would benefit from social interactions with peers.Participant is able to hear, comprehend, and follow directions in order to complete activity with minimal assistance.Participant is 16+ years of ageParticipant is able to independently practice their instrument for a short period of timeI understand the fee for this course is $5.

HOT COCOA & CANVAS - By checking, I agree the participant meets ALL of the requirements for safety and success listed here.*

Consumer would benefit from social interactions with peers.Consumer is able to comprehend, and follow directions in order to complete activity with cues and minimal physical assistance.Consumer can read and comprehend basic words and numbers.Consumer can maintain attention for 15+ minutes.Consumer is able to use words to communicate verbally.Consumer is able to participate appropriately in a small group setting.Consumer is at least 18 years of age and female.

ARTS & CRAFTS - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.

Participant is able to hear, comprehend, and apply basic directions to activities.Participant is able to use words to communicate verbally.Participant has basic fine motor skills to independently utilize art and craft supplies.Participant is able to participate appropriately in a small group setting (4:1 ratio).

REACH FALL EVENT - By checking, I agree the participant meets ALL of the requirements for safety and success listed here.*

Consumer is appropriate for a 4 to 1 group setting ratio.Consumer is able to safely eat independently or with minimal assistance.Consumer would benefit from social interactions with peers.Consumer is able to tolerate a dark environment.Consumer has basic fine motor skills to independently utilize art and craft supplies.I understand there is a $10 activity fee for this event.

Do you have any conflicts with the dates of the rEAch courses selected?*

YesNo

Please list the dates you have conflict with.*

Comments/Questions?

I have read the safety and success requirements for my selected course(s)(can be found here: https://www.embracingabilities.com/reach-program/) and agree that this consumer is appropriate for the selected special/edition. Specials/Editions are set up in small groups for a 4:1 ratio. I understand that placement in each course will be reviewed by the intake team to ensure the safety and success of all participants for the final enrollment. *

Please sign above

I understand that hours from the client's budget will need to be allocated to Embracing Abilities under one of the categories: Day Hab (1:4 ratio) or Private Pay. Once accepted we will request the appropriate budget allocation from you and your case manager.*

Please sign above

REACH Registration

Demographic Information

Primary Contact Information

REACH Course Selection

Embracing Abilities 2024 Policies