LIFE Program Registration
Fill out this form to register for our current LIFE Program. Please make sure to review the consumer safety/success requirements prior to registration. | Please visit our website for additional information: https://www.embracingabilities.com/life-program/
Select the WEST LOCATION LIFE Editions you would like to register for:
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L.I.F.E Social Skills: Ages 18+ (March 14 - April 18)
Consumer's Name
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First Name
Last Name
Are you a current client of Embracing Abilities?
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Select One
Yes
No
Date of Birth
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-
Month
-
Day
Year
Date
Gender
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Male
Female
Client's Guardian Name/Contact Person
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First Name
Last Name
Client's Guardian/Contact Phone Number
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Area Code
Phone Number
Client's Guardian/Contact Email
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Confirmation Email
Current Educational Setting
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General Education
Life Skills
Resource Class
ABA
Other
Safety and Success:
Consumer would benefit from social interactions with peers.
Consumer is able to comprehend, and follow directions in order to complete activity with minimal assistance.
Consumer can read and comprehend basic words and numbers.
Consumer can maintain attention for 15+ minutes.
Consumer is able to use words to communicate verbally.
Consumer will be able to transfer the skills learned to adult living skills.
Consumer is able to participate appropriately in a small group setting with males and females of 1:6 ratio or 1:8 ratio. Consumer is at least 18 years of age and able to participate in basic daily living skills
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I have read the above requirements for safety and success and agree that this consumer is appropriate for the selected edition. Editions are set up in small groups ratios. I understand that placement in each edition will be reviewed by the intake team to ensure the safety and success of all participants and the final enrollment.
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Please sign above
I understand this is a private pay program and is not funded through waiver or insurance. Payments are due upon confirmation of consumers place in the course. Confirmation of place in course is not final until application is reviewed and payment is received.
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Please sign above
How did you hear about us?
Waiver Case Manager/Pick List
Facebook
Friend/Family Member
Caregiver
Current Embracing Abilities Family
Google
Drive by
Other
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