Creating Your Family Mission Plan: Critical School-To-Community Transition Planning For

Creating Your Family Mission Plan:
Critical School-to-Community Transition Planning for Youth with Disabilities

Application for Spring 2016

This series will consist of three seminars, starting with a Saturday kickoff and a Wednesday and Monday evenings, that will provide valuable information, resources and guidance to young adults embarking on adulthood and their caretakers.

The seminars will have two separate tracks, one for parents (and/or guardians, caretakers or adult siblings) and one for youth with intellectual and developmental disabilities and recent graduates, between the ages of 14-26.

The parent/caretaker is required to commit to attending all 3 sessions; and it is optional for the child to attend. Sessions are: Saturday, 4/9, 9am to 3pm (with breakfast and lunch served), Wednesday, 4/13, 5pm to 8:30pm (with dinner served); and Monday, 4/18; 5pm to 8:30pm (with dinner served).

Cost of the 3-day workshop is FREE for Members of The Arc of Loudoun; and $45 for non-members. **Scholarships available with staff referral. Please contact Melissa Heifetz: with any questions.

Parents/guardians and young adults will breakout to attend different workshops in separate areas. Care attendants are strongly encouraged.

Contact Information

Name(s)
Relationship to Young Adult
Street Address
City ST ZIP Code
Home Phone
Work Phone
E-Mail Address

Student Information

Name of Young Adult
Age of Young Adult
Birth date of Young Adult
Primary Diagnosis
Race
Gender
Will Student Attend Workshop? Yes or No
Support Needs of Young Adult – Please describe what types of support the young adult will need in order to participate in the program.
Do any participants in your family need other accommodations? If so, what accommodations and for whom?
Will young adult have a care attendant available, if needed? Include name of attendant if applicable.

Interests

Tell us which areas you are interested in learning more about
___ Medicaid Waivers
___ Social Security
___ Housing
___ Long-term Supports
___ Employment
___ Financial Planning
___ Trusts
___ Recreation
___ Other areas (please list)

Current Knowledge

To better understand your knowledge base, please rank your knowledge on the following subjects.
1 – No knowledge, 2 - A little knowledge, 3 - Some knowledge, 4 - Quite a bit of knowledge, 5 - Expert level of knowledge
___ Medicaid Waivers
___ Social Security
___ Housing
___ Long-term Supports
___ Employment
___ Financial Planning
___ Trusts
___ Recreation
___ Other areas (please list)

Where are you in the process?

Please give us an idea of where you are in the process of obtaining the following adult services

Have not applied, have not made any progress, have not looked at
Have applied, on waiting list
Have, have in place for future

___ Medicaid Waivers
___ Social Security – using EDCD now, wait list for MR waiver
___ Housing
___ Long-term Supports
___ Employment
___ Financial Planning
___ Trusts
___ Recreation

Dietary restrictions

Does anyone attending the program have any dietary restrictions and/or allergies? Please list all below

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted into this program, there is an expectation that my family and I will be able to attend all 3 sessions.
Name (printed)
Date

Our Policy

Space in this program is limited. It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.
Cost of this 3-day workshop is FREE for Members of The Arc of Loudoun; and $45 for non-members. **Scholarships available with staff referral. Please contact Melissa Heifetz: with any questions.

Please fax, email, or mail your application for this program to:

Melissa Heifetz

ALLY Advocacy Center

601 Catoctin Circle NE

Leesburg VA 20176

(Fax) 703.777.1935