An Enrichment Program for Adults with Special Needs

Matthew’s Ministry

Application for Enrollment

(revised 7/22/13)

The Sonflower Adult Learning Program is a ministry of the United Methodist Church of the Resurrection. The following information is confidential. The United Methodist Church of the Resurrection will not disclose information to any third party or make use of information for purposes not related to the acceptance of this applicant into Sonflower Adult Learning Program.

Mission: To extend the love and message of Jesus Christ to all persons with special needs and to help incorporate them fully into the life of the church.

Purpose: To provide a Christ-centered program where adults with special needs engage in fellowship, enriching activities and serve the community while becoming deeply committed Christians.

This application is the first step in determining the eligibility of each Applicant for Sonflower Adult Learning Program. Please complete this application as thoroughly as possible and return to:

The United Methodist Church of the Resurrection

Attention: Sonflower Adult Learning Program/Program Coordinator

13720 Roe Ave.

Leawood, KS 66224

General Information Date ______

Applicant’s Full Name ______Birth Date _____/______/_____

Applicant’s Preferred Name ______

Street Address______City______

State______Zip______Home Phone (______) ______

Is Applicant a member of Church of the Resurrection? ______

Height______Weight______Male______Female______

Is Applicant his/her own legal guardian? ______If no, please complete the following:

Parent and/or Financial Legal Guardian______

Relationship to Applicant______Address______

Home Phone ______Cell Phone______

Email (required) ______Do you check your email regularly?______

Parent and/or Financial Legal Guardian______

Relationship to Applicant______Address______

Home Phone ______Cell Phone______

Email (required) ______Do you check your email regularly?______

Person Applicant Resides With (if different from above):

Name______Relationship to Applicant ______

Home Phone ______Cell Phone ______

Other Support System:

Name ____________Relationship to Applicant ______

Address ______Cell Phone______

Name ____________Relationship to Applicant ______

Address ______Cell Phone______

Name ____________Relationship to Applicant ______

Address ______Cell Phone______

References (Required)

(Two individuals other than the legal guardian who have known the applicant well for at least a year)

1-Reference Name ______

Address / City / State ______

Daytime Phone or Cell Phone ______

2-Reference Name______

Address / City / State ______

Daytime Phone or Cell Phone ______

Is Applicant able to stay at home alone? ______

In a group setting, would the Applicant require one-on-one care? ______

If yes, explain ______

Sonflower Adult Learning Program is not able to provide one-on-one care for Learners. If it is determined by Sonflower Adult Learning Program (SALP) staff that the applicant needs one-on-one care, the applicant will not be accepted into SALP. If the Applicant is accepted into the program and within the 30 day trial period, it is determined the Applicant needs one-on-one care, the individual will not be able to remain in SALP unless a care provider is provided by guardians for the individual’s one-on-one care.

Financial Information

Sonflower Adult Learning Program tuition averages $25.00 per day and is paid monthly.

Person responsible for the financial commitment:

Name______

Address / State / Zip ______

Home Phone ______Cell Phone ______

Email ______

Applicant Experiences

Did the applicant attend high school? ______If yes, last grade completed______

Name of School______Year last attended ______

Check all situations Applicant has participated in and complete the information that follows.

______Day School _____State School _____Sheltered Workshop _____ Private School

______Group/Family Care Home ______Employment ______Independent Living Situation

______Volunteer ______Other/Explain ______

1-Name of School/Facility/Center______

Dates attended ______

Address / State / Zip ______

Type of Situation (refer to preceding list) ______

Reason Applicant Left ______

Contact at School/Facility/Center for more information:

Name ______Position ______

Daytime Phone______

2-Name of School/Facility/Center______

Dates attended ______

Address / State / Zip ______

Type of Situation (refer to preceding list) ______

Reason Applicant Left ______

Contact at School/Facility/Center for more information:

Name ______Position ______

Daytime Phone______

Please Answer the Following (if more space is needed, please attach a separate piece of paper.)

Please describe the Applicant’s disability and indicate the challenges and issues facing the Applicant as a result:

______

Please describe the Applicant’s general health and indicate any significant medical concerns in which Sonflower Adult Learning Program (SALP) should be advised to enable SALP to maintain the safety and protection of the Applicant:

______

Please describe any behaviors that SALP should be aware of and the most effective response to these behaviors:

______

How does the Applicant ambulate:

walks ____ wheelchair____ motorized wheelchair______walker _____

Does the Applicant need assistance ambulating? ______If yes, explain ______

______

Is the Applicant:

Predominantly Verbal _____ Somewhat Verbal _____ Predominately Non-Verbal ______

How does Applicant communicate? Please circle and explain if necessary:

Verbal Sign language Pecs Other Assistance

______

Does the Applicant read? ______If yes, what reading level? ______

Please describe Applicant’s personality: ______

What assistance does the Applicant need on a daily basis? ______

Please describe Applicants daily routine and leisure activities: ______

What are some of the Applicant’s interests? ______

Please describe activities, area, and/or situations that the Applicant strongly dislikes or fears: ______

Please describe the Applicant’s strengths: ______

Please describe your goals and expectations for the Applicant in this program: ______

Please answer the following questions by circling yes or no:

YES NO Is the Applicant physically aggressive? If yes, describe behavior: ______

______

YES NO Is the Applicant verbally aggressive? If yes, describe behavior: ______

______

YES NO Does the Applicant participate in self-stimulatory behaviors? If yes, describe: ______

______

YES NO Has Applicant ever been physically abusive to self? If yes, describe behavior: ______

______

YES NO Has Applicant ever engaged in sexual misconduct? If yes, describe behavior:

______

YES NO Does Applicant have a tendency to wander off?

YES NO Does Applicant put random items in his/her mouth?

YES NO Does Applicant frequently choke?

YES NO Does Applicant need assistance in the rest room? If yes, please describe the assistance needed: ______

______

YES NO Does Applicant wear pull-ups or depends?

YES NO Does Applicant have sensory issues? If yes, describe: ______

______

YES NO Does Applicant have a drivers license? If yes, does the Applicant currently drive? ______

YES NO Has the Applicant used illegal drugs in the past three years? If yes, has the Applicant had treatment and what was the outcome of the treatment? ______

______

YES NO Has Applicant been treated for alcoholism? If yes, date(s) of treatment, outcome of treatment and has Applicant consumed alcohol since receiving treatment: ______

______

YES NO Has Applicant been hospitalized for mental health reasons? If yes, date(s) of treatment, reason for treatment(s):______

______

Was Applicant successfully discharged? ______

Applicant Dietary Needs

Please list any food restrictions or food allergies: ______

______

Can Applicant drink from a glass? ______If no, please explain: ______

______

Does Applicant require supervision/assistance while eating? ______If yes, please explain:

______

Does Applicant require specialized equipment or positioning for eating? ______If yes, please explain:______

______

Health History

If the Applicant is prone to (or has had) problems with any of the following, please circle and explain:

Cold/Sinus Headaches Eyes Ears Chest Asthma

Epilepsy Tuberculosis Heart Kidney Stomach Diabetes

Diarrhea Constipation Fainting Spells Menstrual Cycle

Muscles Neurological

Explanation ______

______

Please list and explain other health concerns not listed above: ______

______

List surgeries or hospitalizations in the last two years: ______

______

Is Applicant on any regular medications? ______If yes, please list below:

______

Please list any medical allergies the Applicant has: ______

______

Important

If there are other factors or anything that you know of that is not listed which would be a factor and could influence the care, health and well being of this Applicant at SALP, please explain:

______

Sonflower Adult Learning Program Selection

Sonflower Adult Learning Program operates from 10:00 am – 3:00 pm Monday-Friday. Minimum enrollment is one day / same day per week. This is not a drop-in program.

Please indicate the days you are enrolling in. Days are subject to availability. (programming subject to change):

_____ Monday – Sonflower Bakery

_____ Tuesday – Art Class / Backpacks for Hunger Ministry

_____ Wednesday – Yoga / Sonflower Bakery

_____ Thursday – Music / Fitness Training

_____ Friday – Sonflower Bakery

(A speech class by KUMC with a separate fee will be offered on a semester basis from 9 am – 10 am on Fridays. Information will be given as classes are offered. Enrollment is separate from SALP and is done through KUMC)

Please make sure that the application is complete and read the statement below and sign.

I affirm that the preceding information is a complete and true statement of all the facts, circumstances, and medical information relative to this Learner’s application for enrollment in Sonflower Adult Learning Program. We, the undersigned, do give our permission for Sonflower Adult Learning Program to contact any or all references, programs, schools, and professionals listed on this application.

Signature of Applicant Date

Signature of Legal Guardian if not Applicant Date

Signature of Member of Support System Date