ABGworks Inc. Enrichment *Employment *Resources Program for Adults with Disabilities

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Participants Name* This field is required.
First Name
Middle Name
Last Name
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Date of Birth* This field is required.
Day
Month
Year
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Address* This field is required.
Street Address
Street Address Line 2
City / Town
County
Postal Code
Please Select
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Afghanistan
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Other
Country
4
Participants Cell Phone Number (Please include if participant has their own cell phone, if not leave blank)
5
Home Phone Number
6
Participants Email(Participants are required to have there own have a Gmail email account set up, call if you need help)
example@example.com
7
Do you give permission to take photos of participant for Social Media & Other.* This field is required.
Yes
No
Other
8
Do you have any Behavioural/Educational Needs that may require special handling or supports?* This field is required.
Yes
No
9
Behavioural/Educational Needs - Please Explain * This field is required.
If this does apply to you please type N/A in the Box
10
Does you suffer from any Medical Conditions?* This field is required.
Yes
No
11
Medical Conditions - Please Explain * This field is required.
If this does apply to you please type N/A in the Box
12
Do you require any medication or medical equipment (Please explain)* This field is required.(Example: Needs assisted technology devise for commication)
If this does apply to you please type N/A in the Box
13
Does you have any allergies or dietary requirements?* This field is required.
Yes
No
14
Allergies or Dietary Requirements - Please Explain* This field is required.
If this does apply to you please type N/A in the Box
15
Is participant currently enrolled with the Agency for Person’s with Disabilities (APD)?* This field is required.
No - no application started
Yes - Enrolled but still on APD waitlist
Yes - APD Medwaiver/iBudget
Yes - APD Medwaiver/CDC+
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Does participant currently need a direct care aid or companion to assist with self care or help participant completing tasks or assignments?* This field is required.
Yes
No
17
Does participant currently have a direct care aid or companion assigned?* This field is required.
Yes
No
18
If participant is registered with a direct care/or companion service agency, please provide the name of the agency that they assigned to, along with the name and cell phone number of assigned companion/aide
If this does apply to you please type N/A in the Box
19
Is participant currently enrolled with the Vocational Rehabilitation (VR)?* This field is required.
No
Yes
20
If participant is registered with Vocational Rehabilitation (VR), what Employment/Transitional Agency are they assigned to?
If this does apply to you please type N/A in the Box
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What high school, home school, or transitional program did the participant graduate from?* This field is required.
If this does apply to you please type N/A in the Box
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Is participant currently enrolled with and receiving Social Security benefits (SSI or SSDI)?* This field is required.
No
Yes
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Is there any further information or special circumstances that we need to be aware of?
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What areas of supports do you need assistance with?
Applying for Agency for Persons With Disabilities (APD)/Medwaiver/ iBudget/CDC+
Applying for Social Security (SSI)
Setting up Guardianship
Setting up Special Needs Trust
Setting Up Able Account
Applying for Vocational Rehabilitation (VR) Employment Services
Finding a Vocational Rehabilitation (VR) Employment Agency
Need Direct Care Aide/ Companion Services
Housing/ Group Home Options
Transportation
Applying for Food Stamps/ EBT
Celebration of Life Planning
Secondary Education- College/ University Options
Vocational Training Options after the age of 22
Caregiver Training for Adults with Disabilities
Mental Health Counseling
Behavioral Health Counseling
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Caregiver Information
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1.) Caregiver Name * This field is required.
First Name
Last Name
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1.) Caregiver Cell Phone Number* This field is required.
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1.) Caregiver Email* This field is required.(Participants are required to there own have a Gmail email account set up)
example@example.com
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1.) Relationship to Participant* This field is required.
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1.) As the caregiver are you interested in working with us as one of our Bright Feats Disabilities Guide Sales Consultants, or as one of our Wisdom Caregiver Consultants or participating as one of our Caregiver~Helper Teams (this is a unique opportunity for you and the participant who may need more supports to work together as a team)? These are independent contractor paid positions😉* This field is required.If you check yes, one of our team members will discuss the details of the opportunity with you in more detail
No
Yes
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1.) Are you interested in serving as one of our ABGworks Volunteer Parent~Helper positions?* This field is required.If you check yes, one of our team members will discuss the details of this volunteer role with you in more detail
No
Yes
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1) If you are interested in participating as one of our ABGworks Volunteer Parent~Helpers, what are your areas of interest or areas of expertise
Interested in working with participants - as part of our teaching team: craft skills, social skills, job skills, other (Tbd)
Interested in working with participants - Help with ABG Thrift & Consignment Boutique Entrepreneurial activities
Community Engagement/Outreach and Resource Information Distribution (
Interested in working with participants - teaching computer/technology skills
Interested in working with participants - athletics activities (basketball, soccer, baseball, tennis, etc)
Interested in working with participants - athletics activities (bowling). ( 2nd & 4th Thursday 12:30-2:30pm)
Willing to help with research or administrative activities
Willing to help with grant writing, funding research, fundraising (Funding Committee)
Interested in helping to researching housing, group home options (Housing Committee)
Interested in helping to researching and kept abreast of Legislative issues that may effect our adult disability programs and services (Legislative Committee)
Other
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2.) Next of Caregiver Name
First Name
Last Name
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2.) Caregiver Cell Number
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2.) Caregiver Email(Participants are required to there own have a Gmail email account set up)
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code? or
Receiving the email may take a few minutes, thank you for your patience!
36
2.) Relationship to Participant
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2.) As the caregiver are you interested in working with us as one of our Bright Feats Disabilities Guide Sales Consultants, or one of our Wisdom Caregiver Consultants or participating as one of our Caregiver~Helper Teams (this is a unique opportunity for you and the participant who may need more supports to work together as a team)? These are independent contractor paid positions😉If you check yes, one of our team members will discuss the details of the opportunity with you in more detail
No
Yes
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2.) Are you interested in serving as one of our Volunteer Caregiver~Helper positions? * Caregivers~Helper volunteer hours can be used to help off-set the cost of the program for participant.If you check yes, one of our team members will discuss the details of this volunteer role with you in more detail
No
Yes
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2) If you are interested in participating as one of our ABGworks Volunteer Parent~Helpers, what are your areas of interest or areas of expertise
Interested in working with participants - as part of our teaching team: craft skills, social skills, job skills, other (Tbd)
Interested in working with participants - Help with ABG Thrift & Consignment Boutique Entrepreneurial activities
Community Engagement/Outreach and Resource Information Distribution (
Interested in working with participants - teaching computer/technology skills
Interested in working with participants - athletics activities (basketball, soccer, baseball, tennis, etc)
Interested in working with participants - athletics activities (bowling). ( 2nd & 4th Thursday 12:30-2:30pm)
Willing to help with research or administrative activities
Willing to help with grant writing, funding research, fundraising (Funding Committee)
Interested in helping to researching housing, group home options (Housing Committee)
Interested in helping to researching and kept abreast of Legislative issues that may effect our adult disability programs and services (Legislative Committee)
Other
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If we are unable to contact any of your contacts in an emergency situation, do you give permission for us to take any necessary action? Including Medical Treatment and Anaesthetic.

This Question is for Emergency Situation Permission, Please select on of the followed below
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Emergency Situation Permission* This field is required.
Yes
No
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The ABGworks Inc. Day Program runs Tue, Wed, and Thur Weekly program cost is $70 per week, if transportation is required and available in your area there will will be an additional cost of $5 per day each way. Participants can opt to participate one or two or three days per week for a cost of $20-$25 per day, if transportation is required that will be an additional cost $5 per day each way. We are planning to implement a virtual component to our program for our participants that are home-bound, this will have cost of $10 per day - our goal is to have virtual participants interface with their team mates for enrichment activities, job training/assignments and activities, and to be able to go out into the community with us on our community outreach adventures.Please use drop down list to select your choice of program options
Interested in the full weekly program (3 days)
Interested in only 1 day per week
Interested in only 2 days per week
Interested in virtual option
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The ABGworks Inc. Enrichment Day Program payment options are as followed - pay by Zelle or Check on Tuesday of each week, or you can choose to pay monthly by the 5th of each month, for caregivers or individuals with disabilities that have financial hardship you can apply for one of our ABG Community Partner Sponsorships. We are also in the process of seeking admittance to be an APD provider and be able to accept CDC+ funding - stay tuned😉. Cash payments accepted, but not preferred.Please use drop down list to select your choice of program options
Pay by Zelle Weekly (Tues) - ABGworks1@gmail.com
Pay by Paypal Weekly (Tues) - ABGworks1@gmail.com
Pay by Check Weekly (Tues) - ABGworks Inc.
Pay by Zelle Monthly (By 5th of month) - ABGworks1@gmail.com
Pay by PayPal Monthly (By 5th of month) - ABGworks1@gmail.com
Pay by Check Monthly (By 5th of month) - ABGworks Inc.
Financial Hardship (Apply for ABG Community Partner Scholarship)
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The ABGworks Inc. Enrichment Day Program Annual Registration Fee (Participant’s entry is included when visiting the BREVARD ZOO through our ABGworks Group Annual PASS ($30), along with one ABGworks Participants Tee-Shirt ($10), Voucher to spend in our ABG Thrift & Consignment Boutique on Wheelz ($10). ~ Thank you for your support ~Please use drop down list to select your choice of options
- Pay Registration Fee of $50 in Full by 8/15/2024 , plus volunteer 2 hrs per month to assist with ABGworks activities, chaperoning trips, fundraising
- Pay Registration Fee of $50 in 2 $25 installments
- Apply for Financial Hardship (Apply for ABG Community Partner Scholarship)
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