Mosaic Minds Program Interest Form
Mosaic Minds creates sensory-friendly, educational, creative and community-based experiences designed to help neurodivergent individuals learn, connect, explore and enjoy new experiences. Please fill out the information below, so we know how to best serve each participant! We will provide you with the appropriate program details following the submission of the form.
Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Text
Call
Email
Relationship to Participant
*
Self
Parent
Guardian
Caregiver/Support Person
Service Coordinator
Other
Funding
*
Alta California Regional Center
SDP
Private Pay
Charter/Homeschool Funds
Not Sure
Other
If you selected Alta California Regional Center, please enter your Service Coordinator's name and email. Please also state if you would like information to sent to your service coordinator for authorization.
Participant Information
Participant Name
*
First Name
Last Name
Participant Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age Group
*
Children
Pre-teen
Teen
Young Adult
Adult
Program(s) You're Interested In
*
Social Groups
Cooking & Life Skills
Movement & Recreation
Creative Activities
Homeschool/Other Programs
Other
Program Delivery Preference
*
In-Person
Virtual
Either
What are you hoping to get out of the program?
*
Social Connection/Friendships
Independence
Cooking/Life Skills
Communication/Self-Advocacy
Movement/Recreation
Sensory-Friendly Activities
Community Participation
Hobbies/Interests/Etc.
Other
What is your favorite hobby?
*
How can we help the participant feel comfortable and successful during the group? (i.e communication preferences, sensory or accessibility needs, etc.)
*
General Availability
*
Weekday Mornings
Weekday Afternoons
Weekday Evenings
Saturday Morning
Saturday Afternoon
Saturday Evening
Sunday Morning
Sunday Afternoon
Sunday Evening
Flexible
How did you hear about us?
*
Instagram
Facebook
Friend/Family
Current Mosaic Minds Family
Employee
Community Event/Organization
Google Search
Other
Anything else you would like us to know?
Would you like to recieve Mosaic Minds program updates, events, announcements by email?
*
Please Select
Yes
No
Do you give consent for Mosaic Minds to gather/use photos of you or the participant?
*
Yes, I consent.
No, I do not consent.
Submit
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