application-form-250210-0

The application form for the Artful Impact creative learning program is designed to determine whether a potential client is a suitable candidate for the program. It gathers essential information about each applicant’s strengths, interests, and support needs, ensuring that we can provide an environment where they can thrive.

The form includes sections on educational background, vocational experience, and daily living skills. Questions also focus on communication abilities, mobility, and social skills to help us understand the applicant’s current level of independence and any areas that might need additional support. Additionally, applicants or their families can share information about personal interests, goals, and previous experiences in work or volunteer settings, helping us assess how well they align with the program’s hands-on, skill-building approach.

This form will serve as an initial step in evaluating whether our program’s structure, resources, and support levels are the best fit for the client’s unique needs and aspirations. This careful selection process helps us ensure that each participant will benefit from the training and contribute meaningfully to our community. Once your application has been submitted, you will receive a confirmation email that it was received. Your application will then be reviewed and we will get back to you within 10 business days. Should you have any additional questions during that time, please don’t hesitate to email artfulimpactstudio@gmail.com .

The privacy and security of our applicants’ personal information are of utmost importance. This policy outlines how we handle the personal information collected through the application process for our vocational training program.

1. Personal Information

A. Purpose of Collection All personal information provided on the application form will be used exclusively to determine the applicant’s eligibility and suitability for the Artful Impact program. This information helps us assess the individual’s needs, strengths, and potential for success in the program.

B. Confidentiality We are committed to safeguarding the confidentiality of all personal information shared with us. Only authorized staff involved in the application and admissions process will have access to this information.
C. Data Security Personal information will be stored in a secure environment, and measures will be in place to protect against unauthorized access, loss, or misuse. Any physical copies will be stored in locked, restricted-access areas.

D. Retention and Disposal Personal information of applicants who are not accepted into the program will be securely destroyed within a month of determination. For accepted clients, personal information will be retained only for the duration of their involvement in the program and any required follow-up period thereafter, after which it will be securely disposed of.
Full Name*
Date of Birth

MonthDayYear
Date
Gender:

FemaleMalePrefer Not to Say
Address
Address
Phone Number
Email Address
example@example.com
Emergency Contact (Name, Relationship, Contact Information):
2. DISABILITY INFORMATION
You may be asked to provide a copy of relevant documents including a current IEP or learning plan.
A. Do you have a disability?

YesNo
Disability Diagnosis (If available)
B. Do you require any specific accommodations for your disability?

YesNo
If you answered yes, please specify. i.e. - Wheelchair access, assistive technology, etc
C. Do you require additional support for any of the following? (check all that apply)

CommunicationPhysical MobilityEmotional SupportReadingWritingDaily Living ActivitiesOther
Please describe if any of the above were checked.
3. HEALTH CONCERNS
A. Do you have any of the following health conditions? (check all that apply)

DiabetesBowel or Bladder ConditionsSeizuresLow VisionHeadaches/MigrainesHearing ConcernsHeart ConditionsRespiratory ConditionsFood or Diet Restrictions/SensitivitiesOther
If you answered ‘other’ above, please describe your health condition.
B. Please provide any additional information regarding any health conditions selectedabove
C. Do you have any specific allergies?

Medication AllergiesFood AllergiesOtherNone
Please describe your specific allergies.
D. Are you currently taking any medications?

YesNo
E. Would you need to take any medications during the time you are at the program?

YesNoMaybe
F. Do you require any special dietary needs? i.e. Gluten Free, Lactose Intolerant, Specialized Diet, etc

YesNoOther
If you answered Yes or Other above, please specify
G. Can you independently complete the following: (check the ones that apply)

Feed YourselfTake medicationRestroomKnow your food/dietary restrictions or allergies if applicableClean yourself after a BMTake care of feminine hygiene
4. Behavior Concerns
You may be asked to provide a copy of a recent behavior intervention plan if applicable.
A. Do you have any behavioral concerns that might affect your participation in the program?

YesNoMaybe
Please describe any potential behavior concerns
B. Have you ever been involved in any of the following behavioral interventions? (select all that apply)

CounselingTherapyMedications to support behaviorBehavioral SupportBehavior Intervention Plan
C. Are you currently involved in any of the following behavioral interventions? (check all that apply)

CounselingMedications to support behaviorTherapyBehavior Intervention PlanBehavioral Support
Please describe the interventions currently being used, how long they have been in place and their effectiveness.
5. EDUCATION I WORK HISTORY
A. High School Attended

Central Catholic High SchoolHarrison High SchoolJefferson High SchoolMccutcheon High SchoolWest Lafayette High SchoolHome SchooledOther
B. Check the box(es) that best describe your high school education level

Exited due to aging outEarned a General DiplomaEarned a Certificate of CompletionOtherEarned an Alternate Diploma
C. Are you currently employed?

NoYes: paid, part-time employmentNo, but volunteeringYes: paid, full-time employment
If you are currently employed, please give your employer name and description of your job.
D. Previous Work Experience - Please list all (include employer, job title and/or job duties)
If you have a transition portfolio that you would prefer to share, that is also an option.
E. Do you have any other vocational experience, certifications or training?

YesNoMaybe
F. Are you able to independently work without supervision?

YesNoMaybe
G. How often do you require assistance when completing tasks?

RarelySometimesOftenAlways
H. Are you able to complete tasks within a given time?

YesNoMaybe
I. What areyourworkpreferences?

Work AloneWork in a teamI like both
6. SOCIAL SKILLS
A. How would you describe your social interaction skills?

ExcellentAverageOtherGoodBelow Average
If yes, please describe.
B. Do you find it difficult to communicate with others?

YesNoMaybe
C. Do you work well in a small group

YesNoMaybe
D. Are you comfortable asking for help when needed?

YesNoMaybe
7. STRENGTHS, HOBBIES AND INTERESTS
A. What are your strengths? (check all that apply)

ReadingOrganizingWritingSortingListeningCreativeSocialHonestKindProblem SolverFunnyPatientHard WorkerAttention to DetailFine Motor Skills - Good with my handsOther
B. Describe your favorite interests or hobbies.
C. What vocational training at this program interests you the most? (select all that apply)

Wood workingSetting up displays in the gift shopWorking with paper, magazine or paintCustomer service in the gift shopWorking with rope or yarnHelping with purchases in the gift shopWorking with fabric or feltAdding inventory to an online storeWorking with jewelry, beads or buttonsPromoting inventory and the program on social mediaWorking with clay or glass
8. QUESTIONS ABOUT YOU
A. What goals do you have for yourself when it comes to work? Why do you want to attend Artful Impact?
B. Is there anything else you would like us to know?
9. REFERENCES
Please provide the contact information for two individuals who can speak to your skills, work habits, and suitability for the program. These references may include former or current teachers, job coaches, supervisors, or other individuals familiar with your abilities and character.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
10. CONSENT AND AGREEMENT
I consent to the processing of this application for the purpose of determining eligibility to attend the Artful Impact, LLC program. Submitting an application does not guarantee acceptance to the program

YesNo
By typing/signing my name, I certify that all the information provided in this application is accurate and complete to the best of my knowledge.

Clear
SIGNATURE
Applicant
Date

MonthDayYear
Date
Guardian
Date

MonthDayYear
Date
SUBMIT FORM
Should be Empty:

1. Personal Information

2. DISABILITY INFORMATION

3. HEALTH CONCERNS

4. Behavior Concerns

5. EDUCATION I WORK HISTORY

6. SOCIAL SKILLS

7. STRENGTHS, HOBBIES AND INTERESTS

8. QUESTIONS ABOUT YOU

9. REFERENCES

10. CONSENT AND AGREEMENT

SIGNATURE

SUBMIT FORM