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)

Full daysHalf daysDrop in
Parent/Guardian Information
Parent/Guardian Name
Relationship to Applicant
Parent/Guardian Primary Phone
Secondary Phone
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
Secondary Phone
Caregiver Address
Caregiver Email Address
example@example.com
Emergency Contacts
Name
Emergency Contact 1
Relationship
Emergency Contact 1
Phone Number
Emergency Contact 1
Name
Emergency Contact 2
Relationship
Emergency Contact 2
Phone Number
Emergency Contact 2
Applicant Medical Background
Primary Disability
Additional disabilities
Medication Allergies
Food Allergies
Applicant Medical Providers
Primary Physician Name
Office Name
Phone
Address
Other Medical Providers
Name
Other Medical Provider 1
Specialty
Other Medical Provider 1
Phone
Other Medical Provider 1
Name
Other Medical Provider 2
Specialty
Other Medical Provider 2
Phone
Other Medical Provider 2
Name
Other Medical Provider 3
Specialty
Other Medical Provider 3
Phone
Other Medical Provider 3
Name
Other Medical Provider 4
Specialty
Other Medical Provider 4
Phone
Other Medical Provider 4
Applicant's Current Medications

Please list the names of current medications & suppliments

	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?

YesNo
If yes, are they able to self-administer these medications?

YesNo
Medical Information
Conditions (check all that apply)

Heart DiseaseHigh Blood PressureADHDAsthmaDiabetesCerebral PalsyPartial Vision LossTotal Vision LossPicaPartial Hearing LossTotal Hearing LossSevere food allergySeizuresStrokeMigrainesDepressionAnxietyOther Mental healthOther
Dietary Restrictions

Dairy FreeGluten FreeLow SugarSugar FreeNoneOther
Adaptive Equiptment

WalkerWheelchairCaneHearing AidsGlasses/ContactsACC or other talking deviceNoneOther
Applicant previous education & training
Primary School K8
High School
College
Employment
Other
Applicant Support

Check all that apply

Applicant Independence

	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)

Independent ActivitiesPartnered ActivitiesSmall Group Activities (3-5)Large Group Activities (5+)Likes to initiate social interactionLikes others to initiatePrefers planned, facilitated activitiesPrefers self facilitating activities
Behaviors (please check any behavior that has been shown within last 6 months)

Verbal outburst or aggressionNoncomplianceUse of bad languagePhysical aggression towards selfPhysical aggression towards othersProperty destructionElopingStealingNoneOther
Behavior description/context:
Common Stressors/Triggers (check all that apply)

Loud noisesChange in routineSmellsSubstitute staff or new peopleBeing touched unexpectedlyTransitioning between activities or roomsPeer behaviorBright or flickering lightsUnfamiliar environmentTexturesCrowded SpacesWaiting or delaysTemperatureSeparation from caregiverNoneOther
Description/context of triggers
Self Regulation Behaviors (check all that apply)

SwingingChewingRockingPacingHolding a preferred objectRepeating words or phrasesRequesting helpJumping or bouncingCountingHumming or singingDeep pressureNoneOther
Incident History
Has the applicant ever been in trouble with the law?

NoYes
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?

NoYes
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:

ExerciseYogaWalkingArtReadingDancingSingingComputer gamingConsol gamingBoard gamesCookingGardeningSportsPuzzlesBuilding or constructingMedia LiteracySewingAnimal CareMoney skillsAll of theseNone of theseOther
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

Clear
Date

MonthDayYear
Date
For Office Use Only
Date Received

MonthDayYear
Date
Reviewed by
Staff Notes
Eligibility

Eligible for interviewNot eligible for interview
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