Open Wings Client Application Form

Open Wings Application Form

Please note you will need to create a JotForm account in order to access the application. This is a free account. If you do not wish to create an account please send an email to lucerito@casademialma.org and request a word document. Please make sure to answer the following questions based on your personal preferences, current situation/state of health and personal experiences.
Confirmation of Submission
- Make sure all fields have been answered
- Upload files as required
- Print a copy for your records
- Press the Submit Button
- After Successful Submission of Application Form, you will get a confirmation message.
Personal Information
Name*

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.
Date of Birth *

DayMonthYear
Nationality*
Marital Status*
Current Address *

Street Address

Street Address Line 2

CityState / Province

Zip CodeCountry

Emergency Contact
Emergency Contact Name*
Phone Number*
Email Address*
Preferred Language*
Relationship to Client*

Medical Information
Primary Care Doctor
Clinic
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Hospital
Food Allergies if any
Do you have health insurance?
Health Insurance Provider?
Health Insurance Member Number
Please take a picture of your health insurance card - FRONT
Please take a picture of your health insurance card - BACK

Acceptance of Terms & Conditions
By submitting your application to the Open Wings Program, you agree to the following:

Eligibility: You acknowledge that your application to the Open Wings Program is subject to review, and acceptance is at the sole discretion of the program administrators. You must meet one or more of the eligibility criteria outlined by the program to be considered for participation.

Commitment: You agree to fully commit to the Open Wings 4 month Program. Failure to actively participate, failure to attend sesssions, or failure to attend therapy appointments will result in removal from the program.

Confidentiality: By applying to the Open Wings Program, you acknowledge that any information shared with the program, including personal, medical, or sensitive data, will be treated with confidentiality. You agree to respect the privacy of others in the program and not disclose any confidential information.

Legal Obligations: You agree to abide by all applicable child reunification legal obligations while participating in the Open Wings Program. Failure to comply with court mandated requirements and appointments may result in immediate removal from the program.

Right to Apply Again: If are not accepted into the program, you acknowledge that you are eligible to reapply in the future. Reapplication is subject to the same terms and conditions, and there is no guarantee of acceptance in subsequent applications.

Disclaimer: The Open Wings Program reserves the right to modify, suspend, or terminate your participation at any time should you fail to adhere to its policies or pose a threat to self and/or others.

By submitting your application, you confirm that you have read, understood, and agree to the above.
Signature

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Date

DayMonthYear
Date
Please ensure the following before pressing the submit button
Should be Empty:

	1	2	3	4	5
Mental Health
Substance Use
Physical Health
Employment/Self Sufficiency
Social Relationships
Housing

Open Wings Application Form

Personal Information

Emergency Contact

Medical Information

Medicine Wheel Framework

Social and Economic

Family and Needs

Personal Health

Community

Acceptance of Terms & Conditions