Basic Information Full Name of Applicant:
Name of Person Completing Application:
Relationship to Applicant:
Home Address:
City
State
Zip
E-Mail Address:
Phone Number
Date of Birth
Current Age:
Does parent or caregiver have guardianship, or is applicant independent?
How did you hear about us?
Other agencies involved with:
NEEDS AND ABILITIES Does the applicant currently have any physical restrictions?
Does the applicant have verbal ability? (If no, please explain their method of communication and how they express their wants and needs)
Is the applicant able to follow multi-step directions?
What are some of the applicant’s hobbies and interests?
Does the applicant have a specific learning style? (Ex: auditory, visual, etc.)
Does the applicant require assistive technology (ex: hearing aid, AAC, sign language interpreter, eye glasses)
VIRTUAL PROGRAM NEEDS Does the applicant have their own email address where weekly Zoom links and other information should be sent? If so, please provide that address below:
SKILLS & ABILITIES Can read simple sentences
Not Yet (Cannot complete at this time) With Full Assistance (Needs full assistance or continuous reminders/help) With Some Assistance (Needs partial assistance or occasional verbal & visual reminders) Independently (Does not need any assistance) Not Sure Can write short sentences
Not Yet (Cannot complete at this time) With Full Assistance (Needs full assistance or continuous reminders/help) With Some Assistance (Needs partial assistance or occasional verbal & visual reminders) Independently (Does not need any assistance) Not Sure Can type simple sentences on a computer
Not Yet (Cannot complete at this time) With Full Assistance (Needs full assistance or continuous reminders/help) With Some Assistance (Needs partial assistance or occasional verbal & visual reminders) Independently (Does not need any assistance) Not Sure Can identify numbers
Not Yet (Cannot complete at this time) With Full Assistance (Needs full assistance or continuous reminders/help) With Some Assistance (Needs partial assistance or occasional verbal & visual reminders) Independently (Does not need any assistance) Not Sure Can identify colors
Not Yet (Cannot complete at this time) With Full Assistance (Needs full assistance or continuous reminders/help) With Some Assistance (Needs partial assistance or occasional verbal & visual reminders) Independently (Does not need any assistance) Not Sure Can identify shapes
Not Yet (Cannot complete at this time) With Full Assistance (Needs full assistance or continuous reminders/help) With Some Assistance (Needs partial assistance or occasional verbal & visual reminders) Independently (Does not need any assistance) Not Sure Can identify letters A-Z
Not Yet (Cannot complete at this time) With Full Assistance (Needs full assistance or continuous reminders/help) With Some Assistance (Needs partial assistance or occasional verbal & visual reminders) Independently (Does not need any assistance) Not Sure Knows right and left directions
Not Yet (Cannot complete at this time) With Full Assistance (Needs full assistance or continuous reminders/help) With Some Assistance (Needs partial assistance or occasional verbal & visual reminders) Independently (Does not need any assistance) Not Sure Can send/receive email
Not Yet (Cannot complete at this time) With Full Assistance (Needs full assistance or continuous reminders/help) With Some Assistance (Needs partial assistance or occasional verbal & visual reminders) Independently (Does not need any assistance) Not Sure In the box below, please provide any additional information that may be helpful in providing the applicant with the best overall virtual learning experience. (The more information, the better!)
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