CASS Academy Small Group Application
CASS Housing does more than just provide individuals with long-term supported housing. CASS offers programs to come beside individuals with developmental and intellectual disabilities to provide opportunities for growth so individuals can learn to thrive in their everyday lives. CASS Academy Small Groups meet weekly for six week sessions. The cost is $120 per session. Acceptance into CASS Academy Small Groups is at the discretion of the CASS Housing Programming Committee.
Applicant Information
Applicant Legal Name
*
Applicant Birthdate
*
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Month
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Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant Email Address
*
Applicant Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please select all that apply.
*
ADD/ADHD
Anxiety
Autism
Cardiac
Cerebral Palsy
Constipation
Developmental Disability
Depression
Diabetes
Down syndrome
Dysphagia
GERD
Hearing Impairment
Impulse Control Disorder
Intellectual Disability
Mobility Impairment
Traumatic Brain Injury - TBI
Visual Impairment
Seizures/Epilepsy
Other
If other was selected, please explain.
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Emergency Contact Information
1. Name
*
First Name
Last Name
1. Relationship to Applicant
*
1. Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
1. Email
*
example@example.com
2. Name
*
First Name
Last Name
2. Relationship to Applicant
*
2. Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
2. Email
*
example@example.com
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Applicant Skills and Needs
How would the applicant be transported to CASS Academy Small Groups?
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What accommodations or supports have been or are being utilized for success in a classroom setting, home, and community?
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Is the applicant able to communicate needs and wants clearly?
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1 - No Support Needed
2 - Minimal Support Needed
3 - Moderate Support Needed
4 - High Support Needed
5 - Full Support Needed
Can the applicant be unsupervised before or after programs while waiting for transportation?
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1 - No Support Needed
2 - Minimal Support Needed
3 - Moderate Support Needed
4 - High Support Needed
5 - Full Support Needed
What level of support does the applicant need to participate in an hour-long academic program?
*
1 - No Support Needed
2 - Minimal Support Needed
3 - Moderate Support Needed
4 - High Support Needed
5 - Full Support Needed
Does the applicant need assistance with toileting?
*
1 - No Support Needed
2 - Minimal Support Needed
3 - Moderate Support Needed
4 - High Support Needed
5 - Full Support Needed
For each of the questions related to medical, safety, and behavior, please highlight anything CASS staff needs to know in order to best understand and support the applicant at CASS Programming.
Safety Needs
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Does the applicant have a history of elopement? If yes, please explain.
*
Medical History
*
Allergies and Dietary Restrictions
*
Does the applicant need assistance with taking medications?
*
1 - No Support Needed
2 - Minimal Support Needed
3 - Moderate Support Needed
4 - High Support Needed
5 - Full Support Needed
Behavioral Concerns
*
Does the applicant have any aggressive behaviors? If yes, please explain.
*
Is the applicant easily redirected if not following directions? If no, please explain.
*
Does the applicant currently work with a Behavior Consultant? If so, please list their name and contact information.
*
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Applicant's Current and Future Goals
How will CASS Academy Small Groups benefit the applicant?
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Does the applicant have a job? If so, where, and how often do you work?
*
What goals does the applicant have related to independence for the future?
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Is the applicant emancipated or do they have a guardian? If the applicant has a guardian, please list the name and contact information of the guardian(s).
*
Is there any other information that you feel would be helpful and important regarding this application for CASS Academy Small Groups?
*
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Documentation
If you not have a PCISP, BSP, or IEP, please provide additional documents to help the CASS Housing Program Committee better understand the applicant's strengths and needs.
Documentation of Developmental or Intellectual Disability
*
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Most Current Person-Centered Individualized Support Plan (PCISP) or IEP, if recent high school graduate
*
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Most current Behavior Support Plan (BSP)
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By signing this application, this is a verification that all information provided is valid and true.
Applicant Signature
Guardian Signature (If Applicable)
Submit Application
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