Sign up Form

Applying for*

Myself

For a loved one

Full name of person seeking services*

Date of birth*

Pronouns*

Primary language*

Other languages

Email (person seeking services)

Phone (person seeking services)

Address*

Street Address City State / Province / Region ZIP / Postal Code

Preferred way to be contacted*

Phone

Email

Text

Primary contact full name*

Relationship to the person*

Primary contact email*

Primary contact phone*

Best time to reach you

Program(s) you are interested in

Recreation Programs

Residential Program

Day Services and Prevocational Program

Community Services

Reimbursement Programs

Desired start timeframe (as soon as possible, 1–3 months, other)*

Days and times available*

Transportation support needed*

Yes

No

Interpreter needed and language

Communication supports preferred

Mobility or accessibility needs

Allergies or dietary considerations

Health or safety considerations we should know

Do you currently have Medicaid?*

Yes

No

Current services or funding*

OPWDD

Medicaid Waiver

Private Pay

Other

Other*

Care manager or support coordinator name and agency

Emergency contact name and relationship*

Emergency contact phone*

Consent to be contacted by phone, email, or text*

Consent to be contacted by phone, email, or text

Consent to store and review information per privacy policy*

Consent to store and review information per privacy policy

I certify the information provided is accurate*

I certify the information provided is accurate

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