Building Abilities Pre-Registration Form

Building Abilities Pre-Registration

This form is not a guarantee of participation. You will be contacted by our Day Services team with next steps.
Participant Information
Participant's Name*

First NameLast Name
Birth Date*

MonthDayYear
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender Identity*

MaleFemaleNon-BinaryChoose not to answerOther
Race/Ethnicity (check all that apply)*

Asian/Pacific IslanderBlackLatinXNative American/Alaskan Native AmericanWhiteChoose Not to AnswerOther
Primary Diagnosis*
Secondary Diagnosis (if applicable)
Supervision (check one)*

Participates in a group setting independentlyParticipates in a group setting independently for short periods of timeParticipates in a group setting with one-on-one support
Does the participant require one-on-one support (or did they when they were in school) or with other services?*

YesNo
Please explain
Participant guardianship status*

Participant is their own legal guardianParticipant has a legal guardianParticipant has co-guardiansI am unsureOther
If Other, please explain
Please upload proof of guardianship, if applicable.

Cancelof
Parent(s)/Guardian(s) Information
Parent/Guardian 1*

First NameLast Name
Phone Number*
Email*
example@example.com
Preferred Length of Day (9a-3p for full day, 9a-12p AM half day, or 12p-3p PM half day).*

Full dayHalf Day - AMHalf Day - PM
Days of week preferred (check all that apply)*

MondayTuesdayWednesdayThursdayFriday
Will the participant require medication on the premises (routine or emergency)?*

YesNo
Does the participant have a behavioral plan in place?*

YesNo
If yes, please upload it here.

Cancelof
Would you like information on financial assistance? (Financial aid is very limited and we cannot guarantee scholarships or discounts. Proof of family income, pay stubs, and tax statements will be required.)*

YesNo
What else do you want us to know?
Other insightful documents (Psychological, IEP, etc.)

Cancelof
Pre-Screen Assessment

In order to be considered for the program, families must attend a Pre-Screening Appointment. Please contact Natasha Pratt (npratt@arctriangle.org) to pick an appointment day and time to meet at Building Abilities - Cisco Campus. Participant AND parent/guardian must be present for this 30 minute meeting.

Pre-Registration Fee *

Pre-Registration Fee

$100.00

Total

$0.00

Credit Card

I here by acknowledge that the information I have provided is accurate to the best of my knowledge. I understand that by filling out this form and paying a non-refundable $50 deposit does not guarantee a place in the program.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

Clear
Should be Empty:

Building Abilities Pre-Registration

Pre-Screen Assessment

Credit Card