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

1
Participants Name* This field is required.
First Name
Middle Name
Last Name
2
Date of Birth* This field is required.
Day
Month
Year
3
Address* This field is required.
Street Address
Street Address Line 2
City / Town
County
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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+
16
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
21
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
22
Is participant currently enrolled with and receiving Social Security benefits (SSI or SSDI)?* This field is required.
No
Yes
23
Is there any further information or special circumstances that we need to be aware of?
24
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
25
Caregiver Information
26
1.) Caregiver Name * This field is required.
First Name
Last Name
27
1.) Caregiver Cell Phone Number* This field is required.
28
1.) Caregiver Email* This field is required.(Participants are required to there own have a Gmail email account set up)
example@example.com
29
1.) Relationship to Participant* This field is required.
30
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
31
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
32
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
33
2.) Next of Caregiver Name
First Name
Last Name
34
2.) Caregiver Cell Number
35
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
37
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
38
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
39
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
40
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
41
Emergency Situation Permission* This field is required.
Yes
No
42
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
43
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)
44
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)
Should be Empty: