Home and & Comm Support Application

Participant’s Name
Nickname
Address
Street Address City State / Province / Region ZIP / Postal Code
Birth Date
MM slash DD slash YYYY
Gender
Participant Phone
Parent/Guardian/Provider Name
Parent/Guardian/Provider Address
Street Address City State / Province / Region ZIP / Postal Code
Parent/Guardian/Provider Home Phone
Parent/Guardian/Provider Work Phone
Emergency Contact Name/Relation
Emergency Contact Address
Street Address City State / Province / Region ZIP / Postal Code
Emergency Contact Home Phone
Emergency Contact Work Phone
Is anyone legally restricted from seeing the participant?
- Yes
- No
Name and relationship of restricted individual
Who should we contact if restriction is violated?
What is the participant’s diagnosis?
Is the participant subject to seizures?
- Yes
- No
Date & severity of last seizure
Please give a description of the participant’s seizures and seizure protocols
Supports Coordinator
Funding Source/Waiver?
How many days are you interested in attending?
Requested Start Date
MM slash DD slash YYYY
Specific Days
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Please answer yes or no to each question below and provide a brief explanation.
Does the individual require supervision or assistance while eating?
Does the individual have any dietary restrictions or food allergies?
Does the individual require specific toileting needs or assistance?
Does the individual have any personal hygiene concerns?
Please list any additional areas of concern or assistance needs in detail
Does the individual utilize a wheel chair or other mobility aids?
Is the individual able to walk or transfer with assistance?
Please allow the applicant to answer each question in detail. This information will be used to help establish areas of interest for the program.
List the characteristics of people you like to be around
List the characteristics of people you don’t like to be around
List positive characteristics about yourself
When you are having a bad day, you usually like to
When you are having a good day, you usually like to
List some of your favorite activities
List some of your least favorite activities
List places in our community where you can participate in activities or volunteer
Do you know anyone that is associated with any of the above activities or places
What are some of your skills that you can use as a volunteer
What assistance would you need from a staff member while volunteer/in the community?
What tasks can you complete independently while volunteering/in the community?
List specific places where you would be interested in volunteering
List specific places in the community that you enjoy
List any additional information about yourself that you would want a staff member to know about you
Please list any additional information about yourself that you would like to share with the places you wish to volunteer or visit
Name of Person Completing Form
Relation to Applicant