New Member Inquiry

Address

Applicant lives with:
I am interested in

Weekday programs SHINE (Saturday Program) Dances
Parent/Guardian Information
Parent/Guardian #1

First Name Last Name
Parent/Guardian #2:

First Name Last Name
Relationship of guardian to applicant

Parent Sibling Other Relative Guardian
Please explain other:
Did the applicant complete a high school or specialized training program?

Yes No Unsure
Please list the state, school name, and year of completion

Address

Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
E-mail
Applicant's health information
Medical Diagnosis
Explanation of applicant's current health condition
Does the applicant have any allergies:

Yes No
List all allergies and reactions
Does the applicant have food restrictions?

Yes No
Please explain food restrictions
Explain any special needs of the applicant
Physician
Personal care
Mobility:
Feeding:
Bathroom:
Group Setting:
Physical concerns

choking falling seizure Elopement (leaving an area without permission)
General information
Has the applicant ever responded aggressively toward a family member, a peer, or caregiver?

Yes No
Please explain
Please list behavioral concerns or tenancies
Have you ever had any incidents requiring the response of law enforcement

Yes No
Please explain
Does the applicant receive Med Waiver/HCBS?

Yes No
Do you utilize the CDC+ program?

Yes No
If accepted to the program, does the applicant have transportation?

Yes No
How did you first hear about Transitions Life Center?
*

I understand the THRIVE program comes with a fee of $35 per day. TLC is an approved CDC+ vendor and individuals who are covered under Consumer Directed Care are eligible to utilize their budget to cover TLC expenses.
*

I have answered all information correctly. False or incomplete information may result in dismissal from program after an individual has been accepted.
Administrative Notes
Should be Empty:

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Applicant Information