Sign Up Form | Living with Purpose Day Program

Which day program are you interested in?

Empower

Inspire

I'm not sure.

Full Name

Birthday

Month

Day

Year

Home Address

Home Phone

Guardian Name

Guardian Address (if different)

Guardian Phone (if different)

Funding Source

ID Number

Service Coordinator

Service Coordinator Number

Does individual have a ISP?

Yes

No

Does individual have a BSP?

Yes

No

Who does the individual live with?

Why are you interested in day program services?

Are you seeking full time or part time enrollment? (Be aware that part time spaces are extremely limited and could impact time on wait list.)

Full Time

Part Time

Please describe the individual’s communication style: (speech, AAC, sign language, gestures, no communication, other)

Does the individual have any criminal history?

Yes

No

Is the individual a registered sex offender?

Yes

No

Can the individual feed themselves?

Yes

No

Will the individual and/or their caregivers be able to send a lunch with the individual each day of program? (This is required.)

Yes

No

Does the individual maintain control of their urinary functions and bowel movements?

Yes

No

Is this behavior predictable?

Yes

No

Is this behavior predictable?

Yes

No

Is this behavior predictable?

Yes

No

Is this behavior predictable?

Yes

No

For Inappropriate Sexual Touching, please select the frequency rating that you feel most accurately reflects the individual:

Is this behavior predictable?

Yes

No

Is this behavior predictable?

Yes

No

Is this behavior predictable?

Yes

No

Is there any other behaviors we should be aware of? If so describe:

Please describe any additional activities:

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