YOUTH SERVICES APPLICATION

Date of Application: MM/DD/YEAR

Please check for which program application applies:

Youth Career Camp Youth Peer Mentorship Program

I. Participant Information/Demographics

Name: (Last)Last Name(First)First Name (Middle) Middle Name

Address:123 Street NameCity:CityState:STZip Code: #####

Home telephone: (###) ###-#### Cell#:(###) ###-####

Email address: ocial Security #:###-##-####

Gender: (check) ☐Male ☐FemaleDate of Birth: MM/DD/YEAR Age: ##

Eligible to Work in the United States?: Y ☐N☐

US Citizen?: Y ☐N☐ If No, specify: Permanent Resident Alien: ☐

Refugee: ☐ Or Visa ☐ Type of Visa: ______

Current School Attending: ______

Date received high school diploma: ______ Expected graduation date: ______

Voluntary response is requested. This information will not be used in a discriminatory nature.

American Indian/Native American ☐ Asian or Pacific Islander☐

Black (non-Hispanic) ☐ Hispanic ☐ White/Caucasian ☐

Resides: (check) ☐Alone ☐Family Home☐Group Home

Legal Status: (check)Competent☐Adjudicated Incapacitated☐

Other guardianship or health care surrogacy: Enter details

(If you have a legal guardian, please indicate name, relationship and contact information such as telephone

numbers, email, and mailing address)

Insert name of legal guardian, relationship, and contact information. If not applicable, insert N/A

Number in household: ______Annual Household Income: $______

(this information is required by a funder, but does not determine eligibility)

Emergency Contact Information:

Name: First and Last

Address:123 Street Name

City:City ST ST Zip#####

Telephone:(###) ###-####

Cell: (###) ###-####

II.Medical Assessment

Diagnosis: Enter client diagnosis. Refer to evaluations and/or support plans

  1. History of illness and physical limitation/restrictions (Clarify as applicable):

Enter details

☐Seizures: Type -☐Petit Mal ☐Grand Mal Frequency - ##

☐Psychiatric Diagnosis/CommentsEnter details

☐Food AllergiesEnter details

☐Asthma/Respiratory Illness Enter details

☐Poor Vision/BlindnessEnter details

☐Hearing loss/Deafness: Enter details

  1. Current Medications: (Please list all)

Medication Name / Dosage / Time(s) Taken / Date Prescribed / Prescribing Physician / Reason
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
  1. Is Participant able to self-administer medications?☐ Yes ☐ No
  2. Hospital Preference in case of an emergency: Enter details

III. Behavioral/Adaptive Skills Assessment

a.☐Self-injurious behavior

Comments: Specify frequency, duration, example of specific behaviors, and possible triggers and/or circumstances under which behaviors occurs

b. ☐Verbally disruptive behavior:

Comments: Specify frequency, duration, example of specific behaviors, and possible triggers and/or circumstances under which behavior occurs

c.☐Unusual fear(s):

Comments Specify types i.e. being touched, loud noises, enclosed spaces, etc.

d. ☐Resistant behaviors:

Comments Specify types i.e. not following directions, etc. specify frequency and circumstances under which behavior occurs.

e. ☐Criminal History (provide details and attach background, if applicable):

Comments: Provide details and attach background information, if applicable.

  1. Please estimate applicant’s ability level in each daily living area, check appropriate number and explain your answer.

1= Can complete task independently with no assistance.

2= Can perform this task with some limited support. (please explain)

3= Can only partially perform this task and/or needs much assistance. (please explain)

4= Cannot perform this task at the present time.

1234

1. Applicant’s ability to toilet self and maintain toileting hygiene:

Comments:______

1234

2. Applicant’s ability to move from one area to another with

or without assistive devices:

Comments:______

1234

3. Applicant’s ability to eat; including feeding self, chewing,

swallowing, cutting, using spoon, etc.

Comments:______

1234

4. Applicant’s ability to self-administer medication:

Comments:______

IV.Educational History check here if you did not complete high school or GED: ☐

A.High School/GED from: Enter name of High School Graduation Date: MM/YY

Address: Street Address, City, State Phone: (###) ###-####

Specify diploma type: Standard, GED, special diploma, certificate of attendance, etc.

B.Other Education from: Enter Info. For Post-Secondary or Trade/Technical School

Address: Street Address, City, State Phone: (###) ###-####

Major: Insert Major Minor: Insert Minor

V.Employment History

Employer: Name of Company Supervisor: Name and Title of Supervisor

Address: Street Address, City, State Phone: (###) ###-####

Start date: MM/YYYYEnd date: MM/YYYY Position: Title of Position

Start Pay Rate: $0.00/hr. Ending Pay Rate: $0.00/hr. Schedule: List hours/schedule

Reason for leaving: State reason for leaving, ex. relocated, laid-off, terminated, etc.

VI. Additional Information: Enter details

The information contained within this application is true and correct to the best of my knowledge.

______/______/______

Signature of the Individual or Legal Guardian Date

______/______/______

Signature of the ARC Representative Date

If you have any questions or comments regarding this application

or need assistance with this applicationplease contact the

Career & Training Development Manager at (954) 746-9400

Form Created 3-31-16; revised 4-5-16

Youth Career Camp

Participant Name: ______

Please select one of the sessions with the dates in which you prefer to attend:

SESSION 1: June 13-17, 9AM-2PM

SESSION 2: June 20-24, 10AM-3PM

SESSION 3: July 11-15, 9AM-2PM

SESSION 4: July 18-22, 10AM-3PM