Creative Living Program Application

New Creative Living program participants (for GetAway Weekends, After School and all other programs) must complete and submit this form below before registering for specific programs or events.

This enrollment form consists of 5 pages and should take 15 minutes or so to complete. Please have the guest's medical information (doctor, insurance, allergies) and emergency contact information handy.

When you're done, don't forget to use the "Submit" button on the last page to send your information.

Which program are you registering for?

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Individual's Information

Full Name(*)

Please type your full name.

Nickname

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Address(*)

Please type your full street address.

City(*)

Please Enter the City Where You Live

State(*)

Please Choose Your State

Zip Code(*)

Please Enter the Zip Code Where You Live

Phone (Home)(*)

Please enter your phone number.

Phone (Cell)

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E-mail(*)

Please enter a valid e-mail address.

Gender(*)

MaleFemalePlease enter your gender.

Date of Birth(*)

Please enter your date of birth.

Legal Competency Status

Guardian

Own GuardianUnder Legal GuardianshipInvalid Input

Name(s) of Legal Guardian(s)

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Address of Legal Guardian(s)

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Phone

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Relation of Legal Guardian to Individual

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Family Information

Individual lives with

Parent(s)Sibling(s) Other relative(s)Invalid Input

Parent / Caregiver 1

Phone (Home)

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Phone (Work)

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Phone (Cell)

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E-mail

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Occupation

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Parent / Caregiver 2

Phone (Home)

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Phone (Work)

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Phone (Cell)

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E-mail

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Occupation

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List household members and their relationship to individual

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List other significant people and pets

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Daily Routine and Preferences

Normal wake up time during the week

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Normal wake up time on weekends

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Normal bedtime during the week

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Normal bedtime on weekends

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Normal bathing time during the week

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Normal bathing time during weekends

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Educational / Leisure / Recreational Interests

Preferences (likes)

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Dislikes

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Special Interests and Hobbies

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School, Grade, Classroom

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Vocational Placement and Role

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Other agency, organization or group associations

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Socialization/Personal Characterization

How does the applicant generally relate to peers?

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... to people in authority (e.g., teachers/staff)?

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Please describe the applicant’s overall personality, noting any behavioral issues, habits, rituals, or triggers. Please touch on the optimal type of environment, special needs (e.g. destim. time, extra emotional support, needs help joining group, prefers to stay on perimeter of group, sensory sensitivities, helpful interventions if getting over stimulated, etc.) which staff should be aware of. How does he/she do in new settings? What helps him/her transition more easily? Please include any other information you feel individual and staff would benefit from knowing.

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Emergency Information

Emergency Contact 1 (Name)

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Address

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Phone

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Relation to Individual

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Emergency Contact 2 (Name)

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Address

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Phone

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Relation to Individual

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Primary Care Physician Name

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Address

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Phone

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Medical Insurer

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Insurance Number

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Medical Condition(s) / Diagnoses

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Current medication(s) and reason why taking

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Allergies

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Blood Type

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Please follow the instructions.

Be sure to submit your form!