TA Admissions Inquiry

Admissions Inquiry
Date of application

MonthDayYear
Date
I acknowledge that I have read and fully understand the Applicant Qualifying Criteria (found on the A New Leaf website) and that the applicant meets the criteria: Please type your name as an electronic signature
I understand that the Hardesty Transition Academy At A New Leaf is a private tuition -based two-year transitory residential, life and workforce skills training and job placement program; for individuals with developmental and or intellectual disabilities (I/DD) and or Autism, who desire to live and work independently. This is not a self-paced program, the maximum length of stay for the program is two years. The academy creates a seamless transition of services by developing, nurturing, and exploring essential/critical skills that support self-sufficiency for I/DD and/or Autism. A New Leaf student will have the opportunity to actively maximize their mental and physical competencies fora vibrant, healthy, and sustainable pathway of independent living through The Hardesty Transition Academy at A New Leaf’s Academy Curriculum. Please type your name as an electronic signature
Who are you submitting for?
Personal Information
Student Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday

MonthDayYear
Date
Birth Country
Gender
Social Security Number
Medicaid Number
Funding Source:
Current Medication List
Allergies
Please check all that apply to you/applicant – past & present: (this information does not disqualify you from ANL services)

Other
Primary Diagnosis:
Secondary Diagnosis
Contact Preferences
What is your preferred method of contact?
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent(s)/Guardian(s) Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
About the Applicant
Does the applicant currently have living arrangements? If yes or no, please explain.
Does applicant have a criminal or juvenile court record? If yes or no, please explain.
How did you find out about The Hardesty Transition Academy at A New Leaf?
Which career field are you most interested in at this time?
What career goals and life skills do you want to obtain?
Are you aware that this is not a free program and that this it is a tuition-basedlife skills and career-readiness transition program?
Education
High School Graduate?
Name of High School Attended
Year Graduated
Did you have an Individual Education Plan (IEP or IP)
Did you Have a Behavioral Plan
College History: Name of college(s)/universities attended
Work History: List all work experience
Vocational Training?
If Yes, list Type, Years, and Agency
What type of work do you/applicant have an interest in doing?

Other
What are your/ applicant’s strengths?
What are your/ applicant’s hobbies?
What are your/applicant’s challenges?
Can you/applicant tolerate high temperatures?
Can you/ applicant tolerate low temperatures?
If no, please explain:
What type of support do you think you/applicant might need from A New Leaf to be successful in our program?
Should be Empty:

Admissions Inquiry

Personal Information

Contact Preferences

Parent(s)/Guardian(s) Information

About the Applicant

Education