Pursuit Center Admissions Application

General Information
Applicant Contact Information*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information*
Secondary Contact Information (Parent or Relative)
Date of Birth*
Current Age*
None/OwnLAR/Guardian
If you are the legal guardian for the applicant, please complete below information
If you selected “LAR/Guardian”, upload a letter of guardianship or other official documentation that confirms legal guardianship to meet this requirement.

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Funding Information
Private PayTexas Home Living Waiver (TxHmL)Home and Community-Based Services (HCS)CLASSContractOther
If you are enrolled with any of the below providers, please list the name of the agency
Medicaid #
Medicare #
Please complete all fields. If you do not have Medicaid and/or primary insurance, please write none in the appropriate blanks.

Program Information
Behavior SupportsCounseling ServicesPursuitJOBS (Employment Support)Pursuit Learning Academy (Individualized Skills and Socialization)Residential ServicesOther
General Program and Service Questions.

Complete core questions (#s 1-6) of this application.
1. What are the participant’s short-term goals?*
2. What long-term outcomes does the participant/guardian hope to achieve from attending the program?*
3. Are there specific skills, interests, or objectives the participant would like to work on?*
4. Participant Preferences: Please identify Individual's Likes / Enjoys*
5. Participant Preferences: Please identify Individual's Dislikes/Avoids*
YesNo

Upload Application Documentation
DID-Determination of Intellectual Disability or Proof of Disability*

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Inventory for Client and Agency Planning (ICAP)*

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Participant's Texas Identification Card*

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Physical Examination (Please upload your most current physical examination completed by a licensed healthcare provider. This documentation must reflect your present health status and be dated within the past 12 months).*

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Acknowledgement Statement

I hereby certify that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any false or misleading information may result in the denial or withdrawal of my consideration to proceed with admission. By signing and submitting this application, I authorize Pursuit Center to verify the information provided and to obtain any necessary records or documents to support this application.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Rows	Date	List or Describe Hospitalization/Surgery/Illness
Occurrence 1
Occurrence 2
Occurrence 3
Occurrence 4

General Admissions Application