SkyLARK Young Adult Program Application 2024-2025

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Thank you for your interest in our SkyLARK young adult program. Please complete this application and a member of our staff will be in touch as soon as possible to confirm your spot. Once an interview is completed, in order to hold your spot in our program, you will be asked to pay a 1 month, non-refundable deposit. The monthly tuition for the 3-day program is $2,400.

Email *

Participant's First Name *

Participant's Last Name *

Participant's Date of Birth *

YYYY

Home Address (Street, City, State, Zip) *

Does the participant have decision making power for themselves or do they have a legal guardian?

Independent decision making

Decisions are shared or made by guardian

Clear selection

Authorized Contact Person Name (parent, guardian, advocate, etc.) *

Authorized Contact Person Phone Number (parent, guardian, advocate, etc.) *

Authorized Contact Person Email Address (parent, guardian, advocate, etc.) *

Authorized Contact Person Relationship to Participant *

Emergency Contact Name (different from above) *

Emergency Contact Phone Number (different from above) *

Emergency Contact Email Address (different from above) *

Emergency Contact Relationship to Participant *

Please list all languages spoken in participant's home *

Please describe participant's strengths and interests *

Please describe areas in which participant requires additional support, education and/or practice. *

Please list any medical, behavioral, or academic diagnoses participant has received (if applicable)

Please describe areas in which participant is currently undergoing therapy (OT, PT, speech, counseling, etc.)

Please rate the importance of the following goal areas for the participant

Very Important

Somewhat Important

Minimally Important

Independent Living Skills (Self-care, personal safety, fitness, recreational)

Social & Communication Skills (self-advocacy, self-regulation, relationship building)

Employment Readiness (vocational skills, workplace technology)

Executive Function (organization, time management, goal setting)

Functional Academics (personal finances, budgeting)

Clear selection

Please list any known food or environmental allergies participant has (if applicable)

Please select participants first choice for program *

3 day (M/W/F 9:00-2:00)

2 day (T/Th 9:00-12:00)

Other:

How did you learn about the SkyLARK young adult program at The Lark Center? *

Current or former client

Word of mouth

Facebook

Google

Live event

Referral from school or doctor

Walk/drive-by

Other:

Is there anything else the participant would like us to know?

A copy of your responses will be emailed to the address you provided.

Submit

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