PARTICIPANT INTAKE FORM

PARTICIPANT INTAKE FORM
Welcome to the Self-Determination Program! As your Financial Management Service (FMS), we will help you manage your approved budget, pay for support, and make sure your spending follows the Department of Developmental Services (DDS) rules.

Please have following Documents Ready to Upload or Reference:

·         Regional Center Budget Authorization

·         Copy of Approved Spending Plan (from Regional Center)

·         Identification (license, state ID, passport, etc.)

PART A: PARTICIPANT INFORMATION
Name*

First NameLast Name
DOB

MonthDayYear
Date
UCI
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Language
If other, please specify
Upload a picture of your Government Issued ID

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Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Relationship
If other, please specify
Emergency Contact Legal Authority

PART C: PARTICIPANT RIGHTS & RESPONSIBILITIES
• I understand it is my responsibility to submit timesheets/invoices on time.
• I agree to stay within my approved budget.
• I understand the FMS will send me monthly reports.
• I will inform the FMS and Regional Center of any changes.
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Representative Name

First NameLast Name
Relationship
Representative Signature Box

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Date

MonthDayYear
Date
Participant Signature

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Date

MonthDayYear
Date
- LEAVE BLANK FOR FMS REPRESENTATIVE
- FMS Rep Name
  
  First NameLast Name
- FMS Rep Signature
  
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- Notes/Comments
- Date
  
  MonthDayYear
  Date
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