REACH Registration

Name of Participant (If you are signing up for more than one participant, please fill out a separate form for each participant) *

First NameLast Name

Date of Birth*

Date

Gender*

MaleFemale

Last Four of SSN (Waiver Recipient)*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County of Residence*

Are you a current client of Embracing Abilities?*

Funding Source*

Parent/Guardian/Self:*

First NameLast Name

Parent/Guardian/Self Phone Number*

Email*

example@example.com

Case Manager's Name*

First NameLast Name

Case Manager's Email*

Confirmation Emailexample@example.com

Select the WEST REACH Edition(s) you would like to register for:

Cooking Class: Tuesdays 5:30-7:30 PM (November 8, 25 & December 2, 9, 16, 23)

Select the WEST REACH Special(s) you would like to register for:*

Jingle Jam (December 11, 2025 6-8pm)Hot Cocoa and Canvas (December 17, 2025 6-8pm)Drive Thru Winter Wonderland Lights (December 18, 2025 6-8pm)

Select the NORTH LOCATION REACH Editions you would like to register for:

Cookie Decorating (All Ages) - Wednesday, December 13th, 2023 - 6:00-8:00 PM

WINTER CRAFT NIGHT | REACH SPECIAL - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.*

Consumer is appropriate for a 4 to 1 group setting ratio.Consumer would benefit from social interactions with peers.Consumer is able to hear, comprehend, and follow directions in order to complete the activity with minimal assistance.Consumer has basic fine motor skills to independently utilize art and craft supplies.I understand there is a $10 activity fee for this event.

COOKIE DECORATING | REACH SPECIAL - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.*

Consumer is appropriate for a 4 to 1 group setting ratio.Consumer is able to safely eat independently or with minimal assistance.Consumer would benefit from social interactions with peers.Consumer has basic fine motor skills to independently utilize art and craft supplies.I understand there is a $10 activity fee for this event.

POLAR EXPRESS | REACH SPECIAL - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.*

Consumer is appropriate for a 4 to 1 group setting ration.Consumer would benefit from social interactions with peers.Consumer enjoys movies and is able to attend in an appropriate manner.Consumer is able to tolerate a dark environment and occasional loud noises.Consumer is able to remain sitting for a movie.I understand there is a $10 activity fee for this event.

EA Rocks! Music Group - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.

Participant is appropriate for a 4:1 group setting ratio.Participant would benefit from social interactions with peers.Participant is able to hear, comprehend, and follow directions in order to complete activity with minimal assistance.Participant is 16+ years of ageParticipant is able to independently practice their instrument for a short period of timeI understand the fee for this course is $5.

Cooking Class - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.*

Consumer is able to hear, comprehend, and apply basic safety directions to activity.Consumer is able to physically use/hold kitchen tools/appliances independently.Consumer will utilize these skills independently in the future.Consumer is able to participate appropriately in a small group setting.

JINGLE JAM - By checking, I agree the participant meets ALL of the requirements for safety and success listed here.*

Consumer is appropriate for a 4:1 group setting ratio.Consumer is able to tolerate a loud environment with music.Consumer is able to hear, comprehend, and apply basic directions to activities.Consumer has basic fine motor skills to independently utilize art and craft supplies.

HOT COCOA & CANVAS - By checking, I agree the participant meets ALL of the requirements for safety and success listed here.*

Consumer would benefit from social interactions with peers.Consumer is able to comprehend, and follow directions in order to complete activity with cues and minimal physical assistance.Consumer can read and comprehend basic words and numbers.Consumer can maintain attention for 15+ minutes.Consumer is able to participate appropriately in a small group setting.

DRIVE THRU WINTER WONDERLAND LIGHTS - By checking, I agree the participant meets ALL of the requirements for safety and success listed here.*

Consumer is appropriate for a 4:1 group setting ratio.Consumer can ride safely in a vehicle with others.Consumer is able to tolerate a dark environment.Consumer is able to tolerate bright and occasional flashing Christmas lights

ARTS & CRAFTS - By checking I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.

Participant is able to hear, comprehend, and apply basic directions to activities.Participant is able to use words to communicate verbally.Participant has basic fine motor skills to independently utilize art and craft supplies.Participant is able to participate appropriately in a small group setting (4:1 ratio).

REACH Grateful Gathering - By checking, I agree the participant meets ALL of the requirements for safety and success listed here.*

Consumer is appropriate for a 4 to 1 group setting ratio.Consumer is able to safely eat independently or with minimal assistance.Consumer would benefit from social interactions with peers.Consumer is able to tolerate a dark environment.Consumer has basic fine motor skills to independently utilize art and craft supplies.I understand there is a $10 activity fee for this event.

Do you have any conflicts with the dates of the REACH courses selected?*

YesNo

Please list the dates you have conflict with.*

Comments/Questions?

I have read the safety and success requirements for my selected course(s) and agree that this consumer is appropriate for the selected special/edition/club. Specials/Editions/Clubs are set up in small groups for a 4:1 ratio (or larger). I understand that placement in each course will be reviewed by the intake team to ensure the safety and success of all participants for the final enrollment. *

Please sign above

I understand that hours from the client's budget will need to be allocated to Embracing Abilities under one of the categories: Day Hab (1:4 ratio) or Private Pay. Once accepted we will request the appropriate budget allocation from you and your case manager.*

Please sign above

REACH Registration

Demographic Information

Primary Contact Information

REACH Course Selection

Embracing Abilities 2025 Policies