CoreMember Inquiry

Core Member Inquiry Form

Thank you for your interest in L’Arche Frederick! This form is intended for an adult who has an intellectual disability (or their advocate) to express interest in living in L'Arche as a "member." The form is not an official application and does not guarantee placement in a L’Arche home. L’Arche does not have a first-come-first-served waiting list, but should there be an opening in a L’Arche home, we will contact those who have completed an inquiry form.
Name of the Person Completing this form:*

First NameLast Name
Email address:*
example@example.com
Relationship to Interested Person/Core Member:
With whom does the Core Member live? *

Parent/GuardianSiblingFamily MemberNursing HomeGroup HomeAlone/With RoommateOther
Current Primary Caregiver (If different from person completing form):
Core Member Basic Information
Name of the Interest Person/Core Member:*

First NameLast Name
Date of Birth:*

MonthDayYear
Gender?*
Email address:*
example@example.com
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Core Member's Disabilities or conditions (please check all that apply):*

AutismBehavior ChallengesBlindness/Severe Visual ImpairmentCerebral PalsyChemical Dependency (specify)Deafness/Severe Hearing ImpairmentDiagnosis of Mental IllnessEpilepsy/Seizure DisorderTraumatic Brain InjuryIntellectual DiabilitySpecific Learning DisabilitySpeech ImpairmentSpinal Cord InjuryUndeterminedOther
At what age was the disability first diagnosed?
Care Needs
Ambulation (ability to sit, stand, walk):*
Need for transfer assistance (to move from one place of rest to another):*
Need for assistance with eating:*
Need for assistance with toileting and/or bathing:*
What is the core member's primary means of communication? *
Safety Issues (please select all that apply):*

History of challenging sexual behaviorsHomicidal IdeationElopementSubstance Abuse or MisuseProperty DestructionSuicidal IdeationSlip and/or Fall RiskPICA (craving to eat non-food items)HoardingFood SeekingNoneOther
Funding Sources and Services
Sources of funding available for core member (please select all that apply):*

SSISSDIMedicaid/Medicaid WaiverMedicare Part AMedicare Part BPrivate Health InsuranceFamily or Personal FundsSpecial Needs TrustOther
If you currently have a Medicaid Waiver, please specify which one:
If you do not currently have a Medicaid Waiver, have you applied for one?
Does the core member currently receive services through DDA?         Yes    No
If yes, which services?       Type of waiver
If no, is the core member eligible for funding from the state of MD? Yes     No
L'Arche Involvement

Previous and/or Current
Have you attended any L'Arche Frederick Community events in the last 2 years?
No, we do not have the capacity to attend because: Reason
No, but we plan to start attending
Yes, one event: Which Event?
Yes, two or more events:
Have you visited the L'Arche Frederick House? Select one.*

No, but I would like toYes, onceYes, more than onceOther
How long have you been involved with the L'Arche community; through community events or other interactions? Select one.*

I have not been involved yet.Less than a year1-3 yearsMore than 3 yearsOther
What gift(s) do you see in yourself that make you shine?
Tell us about yourself
As we are selecting our core members, we will seek racial and economic diversity. We seek to offer openings to those who need it most. The following questions are optional.
What is your race?

America Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhitePrefer not to answer
What is your family's adjusted gross income (an estimate is okay)?

Below $20,000$20,000-$40,000$40,000-$60,000$60,000-$75,000$75,000-$100,000100,000+UnknownPrefer not to answer
L'Arche Frederick does not discriminate on the basis of race, religion (creed), color, ethnicity, national origin, sex, sexual orientation, gender identity and expression, age, height, weight, physical or mental ability, veteran status, military obligations, or any other characteristic protected under applicable federal or state law.
Should be Empty:

Core Member Inquiry Form

Core Member Basic Information

Care Needs

Funding Sources and Services

L'Arche Involvement

As we are selecting our core members, we will seek racial and economic diversity. We seek to offer openings to those who need it most. The following questions are optional.