The Resting Tree Program Participant Application

Date

MonthDayYear
Date
Requested Starting Date

MonthDayYear
Date
Applicant Information
Applicant's Name
Applicant's DOB
Applicant's Race
Applicant's Gender
Applicant's Age
Applicant's Address
City
State
Zip Code
Applicant's Primary Language
Applicant's Secondary Language
Schedule
Requested Schedule (select all that may apply)
Parent/Guardian Information
Parent/Guardian Name
Relationship to Applicant
Parent/Guardian Primary Phone
Format: (000) 000-0000.
Secondary Phone
Format: (000) 000-0000.
Parent/Guardian Address
Parent/Guardian Email Address
example@example.com
Does the parent/guardian have legal guardianship over the participant?
Caregiver information (if different than parent/guardian)
Caregiver Name
Relationship to Applicant
Caregiver Primary Phone
Format: (000) 000-0000.
Secondary Phone
Format: (000) 000-0000.
Caregiver Address
Caregiver Email Address
example@example.com
Emergency Contacts
Name
Emergency Contact 1
Relationship
Emergency Contact 1
Phone Number
Emergency Contact 1Format: (000) 000-0000.
Name
Emergency Contact 2
Relationship
Emergency Contact 2
Phone Number
Emergency Contact 2Format: (000) 000-0000.
Applicant Medical Background
Primary Disability
Additional disabilities
Medication Allergies
Food Allergies
Applicant Medical Providers
Primary Physician Name
Office Name
Phone
Format: (000) 000-0000.
Address
Other Medical Providers
Name
Other Medical Provider 1
Specialty
Other Medical Provider 1
Phone
Other Medical Provider 1Format: (000) 000-0000.
Name
Other Medical Provider 2
Specialty
Other Medical Provider 2
Phone
Other Medical Provider 2Format: (000) 000-0000.
Name
Other Medical Provider 3
Specialty
Other Medical Provider 3
Phone
Other Medical Provider 3Format: (000) 000-0000.
Name
Other Medical Provider 4
Specialty
Other Medical Provider 4
Phone
Other Medical Provider 4Format: (000) 000-0000.
Applicant's Current Medications

Please list the names of current medications & suppliments

Rows	Name of Medication	Reason for Medication
1
2
3
4
5
6
7
8
9
10

Will the applicant need to take any of the above medications during program hours?
If yes, are they able to self-administer these medications?
Medical Information
Conditions (check all that apply)

Other
Dietary Restrictions

Other
Adaptive Equiptment

Other
Applicant previous education & training
Primary School K8
High School
College
Employment
Other
Applicant Support

Check all that apply

Applicant Independence

Rows	Completes Independently	Needs some help and/or prompting	Needs significant help / can not do	N/A
Toileting
Manage menstrual hygiene
Eating/drinking
Communicating
Follow simple directions
Cleaning up after self
Keep track of personal belongings
Understand basic safety rules

Social Preferences (check all that apply)
Behaviors (please check any behavior that has been shown within last 6 months)

Other
Behavior description/context:
Common Stressors/Triggers (check all that apply)

Other
Description/context of triggers
Self Regulation Behaviors (check all that apply)

Other
Incident History
Has the applicant ever been in trouble with the law?
If yes, explain
Has the applicant ever been asked to leave or discharged from any previous program or service due to behavioral concerns or challenges?
If so, please explain the circumstances.
Applicant Interests
What are your job/vocational interests?
Are you involved in any community activities (such as volunteering, clubs, etc.)?
What are your hobbies?
Favorite topics characters or themes?
Do you have any pets?
What is your favorite movie or show?
What is your favorite food?
Where are your favorite places to go?
What are your favorite games?
What makes you feel happy, safe, or calm?
What would you like us to know about you?
Additional Likes & Dislikes
Are you interested in participating in or learning about any of the following activities:

Other
By signing below, you certify that all information provided in this application is complete, accurate, and truthful to the best of your knowledge. Any misrepresentation, omission, or falsification of information regarding the applicant's abilities, behaviors, or needs may result in immediate termination from the program. Completion of this application does not guarantee acceptance into The Resting Tree program. All applicants will undergo a screening and interview process to determine eligibility for our services.
Applicant printed name
Guardian printed name
Applicant/Guardian Signature
Date

MonthDayYear
Date
For Office Use Only
Date Received

MonthDayYear
Date
Reviewed by
Staff Notes
Eligibility
Should be Empty:

Applicant Information

Schedule

Parent/Guardian Information

Caregiver information (if different than parent/guardian)

Emergency Contacts

Applicant Medical Background

Applicant Medical Providers

Other Medical Providers

Applicant's Current Medications

Medical Information

Applicant previous education & training

Applicant Support

Incident History

Applicant Interests

For Office Use Only