Application Form

Participant Information

Applicants Full Name *(Required)

First Last

Preferred Name (if any)

Date of Birth(Required)

Current Age(Required)

Email Address(Required)

Phone Number(Required)

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Method of Contact(Required)

Phone

Text

Name of Person Completing Application(Required)

Relationship to Applicant(Required)

Does parent or caregiver have guardianship, or is participant independent?(Required)

Yes

How did you hear about us?(Required)

Skills and Abilities

Can read simple sentences(Required)

Can write short sentences(Required)

Can type simple sentences on a computer(Required)

Can identify numbers(Required)

Can identify colors(Required)

Can identify shapes(Required)

Can identify letters A-Z(Required)

Can identify money(Required)

Can send/receive email(Required)

Class Interests

What classes are you interested in?(Required)

Disney Class

Bingo

Broadway

Trivia, Music & Movies

Learners Choice

National Holidays

Science and Nature

What are the participant’s hobbies and interests?(Required)