Interest Form for Imagine That!

Interest Form for Imagine That!
If you are an adult with an intellectual or developmental disability and are interested in exploring your creativity, please fill out this interest form. Please note filling out this form does not guarantee a spot in our program. All artists must go through a formal interview and assessment process before the determination is made. When the interest form has been completed, someone from Imagine That will contact you.
To qualify for our services, you must meet the following criteria:
- Diagnosed with a qualifying intellectual or developmental disability before the age of 22.
- Completed high school.
- Live in Jackson, Platte or Clay County in Missouri.
- Demonstrate a genuine interest in being creative and learning more about the art-making process.
- Demonstrate the ability to accept and follow reasonable rules and expectations.
- Demonstrate respectful and positive interactions with peers and staff.
- Capable of maintaining behavior which does not pose a danger to oneself or others.
Artist's Name*

First NameLast Name
Artist's Date of Birth*

MonthDayYear
Date
Artist's County of Residence*

JacksonClayPlatteOther
Name of Person Referring the Artist to Imagine That*

First NameLast Name
Relationship to Artist*
Contact Information
Artist's Phone Number, if applicable
Please enter a valid phone number.
Artist's Email, if applicable
example@example.com
Artist's Parent/Guardian/Primary Caretaker's Name*

First NameLast Name
Parent/Guardian/Primary Caretaker's Phone Number*
Please enter a valid phone number.
Parent/Guardian/Primary Caregiver's Email, if applicable
example@example.com
Support Coordination Information

Complete if you have a Support Coordinator
Support Coordinator's Name

First NameLast Name
Support Coordinator's Phone Number
Please enter a valid phone number.
Support Coordinator's Email
example@example.com
Funding Source
Imagine That! is a fee-for-service program. This means we are paid for our services. Please indicate how payment will occur.*

Medicaid Waiver through DMHCurrently applying for a waiver slotPrivate PayAutism Project FundingUnsure
Personal Information
Has the artist attended (or is the artist currently attending) a day program?*

YesNo
If yes, name of program:
If yes, reason(s) for leaving:
What is the artist hoping to get out of their experience at Imagine That?
What type of art does the artist like to make or wants to learn how to make?
Today's Date

MonthDayYear
Date
Should be Empty:

Interest Form for Imagine That!

Contact Information

Support Coordination Information

Funding Source

Personal Information