At-Risk-Together Enrollment Application

Health Information
At-Risk-Together serves a unique and vulnerable population and has many measures in place to mitigate risk.

We rely on disclosure of some health information to ensure we can maintain safety and meet the needs of the population we serve.

This information is used for screening purposes and suitability for our programming, ART respects your privacy and under no circumstances will this information be shared outside outside of the individuals responsible for applications/registration.
Details of why you would prefer At-Risk-Together compared to a typical program*
Are all household members up to date on eligible vaccinations?*

YESNOUNSURE
Please explain why vaccinations are not up to date
Prior to admission, we will need a copy of your child's vaccination records and/or a letter from your physician explaining any scheduled vaccinations that are delayed or not appropriate.
Any other relevant medical history or personal information that would help us understand and meet your child’s needs? e.g. allergies, behavioral concerns, food restrictions (based on health or faith)*

Risk Tolerance & Specific Concerns
Please use this space to help us understand specific concerns about infection control that you may have and any other information regarding your risk tolerance that you feel we should know*
Should be Empty:

Applicant Details