Thank you for your interest in joining CAYAs life skills, BRIDGE program
By completing this application, it does not guarantee a spot in the BRIDGE program. CAYA will follow up with you on next steps and availability shortly after submission. Thank you for being interested in CAYA. We can't wait to work with you!
Personal Information
Today's Date
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Month
-
Day
Year
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Who is completing this form?
Myself (meaning the BRIDGE participant) with no assistance
Myself (meaning the BRIDGE participant) with some assistance
Someone is completing this form on my behalf with my input
Someone is completing this form on my behalf without my input
If someone is assisting or completing on your behalf, please add their name and relationship to you
Example: Jenn Smith, mom
Name
First Name
Last Name
Preferred Name
Age
Date of Birth
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Month
-
Day
Year
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Gender
Male
Female
Other
I do not know
I do not want to answer
What is your race and ethnicity? Please check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino or Latina
Native Hawaiian or Other Pacific Islander
White
Other race or ethnicity
I do not know
I do not want to answer
How did you hear about CAYA?
Please Select
Website
Google Search
Social Media - Facebook/Instagram
News
Podcast
At a community Event
From a Friend!
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Permission to text?
Please Select
Yes
No
Email
example@example.com
Communication Preference
Text
Email
Phone
Face to Face
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where do you live?
City or suburb
Rural area like the countryside
I do not know
I do not want to answer
Which of the follow describes you? Check all that apply. A developmental disability (DD) starts before the age of 22. People with DD often need supports and services for life. Examples include: Down Syndrome, autism, cerebral palsy, hearing loss of deafness, and vision impairment.
I do not have a disability
I have a developmental disability
I have a disability that is not a developmental disability (e.g, learning disability)
I do not want to answer
Do you identify as being neurodivergent? Some examples include: Autism spectrum disorder, ADD/ADHD, dyslexia, social anxiety, OCD, epilepsy
Yes
No
Highest Level of Education
How will you get to/from work and the program?
Please Select
I plan to drive myself
Family will drive me
I will use Uber/Lyft
Public transportation
I do not have transportation
I need assistance with transportation
The BRIDGE Program will be running several times throughout the year. Please indicate which month(s) you would prefer to start the program
January
April
September
Summer Program (an abbreviated 6-week program focused on scheduling, planning, time management, and organization)
Getting To Know You Better
The questions below help us get to know you—your goals, the important parts of your life, and the people and things that matter most to you.
What are your personal goals?
Get a job, move into an apartment, get your drivers license, find a girl or boyfriend
What are some things that are challenging for you?
prioritizing work, staying on task, staying focused
What is one skill you would like to improve this year to be more independent?
What makes you happy and motivates you?
What are the things that upset you?
What concerns do you have about living on your own?
Can you operate a computer independently? Such as using programs like Word and Google
Yes
No
With someone's help
Do you check your email independently?
Yes
No
With someone's help
I know how, but no one emails me
Do you want to be able to manage your healthcare like doctors appointments and prescriptions?
Yes, in the future
No, I prefer someone else to do this for me
I can, with someone's help
Yes, I do this now
Do you know how to manage your money such as making a budget, paying bills, or saving for something special?
No
No, but I want to learn how
Yes, I do this now
I can, with someone's help
Who do you want to live with in the future?
My parents
My own - no roommates
My own with roommates like friends
With a romantic parnter
I haven't thought about it
Do you have a job?
Yes
No, I have never had a job
Not at the moment, but I have before.
What areas are of interest to you
Schedule and calendar planning
Time Management
Understanding myself and my needs better
How to take care of my health, like doctor's appointments and medication
How to cook
Managing household chores
How to get housing
Transportation
Managing money, paying bills, and savings
Employment
You would say working with Caya is a success if you complete what?
For example: If I learned how to manage my money I would be happy working with CAYA.
Do you need financial assistance to cover tuition? Payments can be made in monthly installments.
Yes, please include me for financial assistance.
No, I currently do not need assistance to pay the BRIDGE program fees
Waiver and Release of Liability
In consideration of being permitted to participate in the programs, activities, and events of Come As You Are Inc., I, the undersigned participant, or the parent or legal guardian of the participant, hereby agree to the following: Assumption of Risk: I understand that participating in Come As You Are Inc.’s programs, activities, and events may involve inherent risks, including, but not limited to, physical exertion, interaction with other participants, and exposure to various environments. I voluntarily assume all risks associated with my participation. Release of Liability: I, for myself, my heirs, executors, administrators, and assigns, hereby release, waive, discharge, and hold harmless Come As You Are Inc., its directors, officers, employees, volunteers, agents, and affiliates from any and all claims, demands, liabilities, damages, injuries, actions, or causes of action arising out of or in connection with my participation in Come As You Are Inc.’s programs, activities, or events, including any claims arising out of negligence. Photographic Release: I grant Come As You Are Inc. the right to take photographs and videos of me during the programs, activities, and events. I agree that Come As You Are Inc. may use such images for promotional, educational, and other purposes without compensation to me. Behavior and Conduct: I agree to follow all rules, guidelines, and instructions provided by Come As You Are Inc. staff and volunteers. I understand that failure to adhere to these rules may result in my removal from the program, activity, or event without refund. Confidentiality: I understand that certain information disclosed during my participation in Come As You Are Inc.’s programs, activities, or events may be confidential. I agree to maintain the confidentiality of such information and not disclose it to third parties without the prior written consent of Come As You Are Inc. Indemnification: I agree to indemnify and hold harmless Come As You Are Inc., its directors, officers, employees, volunteers, agents, and affiliates from any and all claims, demands, liabilities, damages, injuries, actions, or causes of action arising out of or in connection with my conduct or actions during my participation in Come As You Are Inc.’s programs, activities, or events.
I Agree with the Above Waiver Conditions
I Do Not Agree with the Above Waiver Conditions
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