JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
ITG GRACE Program Application
Please read all questions carefully and answer to the best of your knowledge. Once this form is submitted, a GRACE team member will be in touch.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Prospective candidate will at minimum, fulfill the following criteria:
18 years of age or older (admission process may begin earlier)
Have a primary diagnosis of developmental disability or cognitive challenge
Be accepting of supervision
Capable of self-care and activities of daily living or provide caregiver if unable to do so (women must take care of monthly menstruation needs or remain at home)
Able to ambulate and/or transfer independently (provide care staff if unable to do so)
Free of impulse to take flight or run away
All medical conditions must be manageable
Free of communicable diseases
Free from patterns of aggression or abuse toward self and others
Able to participate successfully in community with others, and engage in programs and activities to the extent of his/her ability
Provide two letters of recommendation (previous school, current program, family/friend or home church.)
Name of Applicant
*
Full name of prospective participant. May also include preferred name / nickname
Your answer
Phone Number
*
Your answer
Phone number above is...
*
Cell Phone (Able to receive text messages)
Cell phone (NOT able to receive text messages)
Home phone
Address
*
Your answer
Gender
*
Female
Male
Date of Birth
*
MM
/
DD
/
YYYY
Primary Disability
Your answer
Physical disability(s)
Your answer
Medical conditions
Your answer
Medications taken
Your answer
Allergies
Your answer
Seizures
Your answer
Please check any devices used
Glasses
Hearing aid
Dental appliance
Cane
Walker
Wheelchair
Other:
Are there any things/situations that cause anxiety?
Your answer
Controls temper
*
Yes
No
Other:
History of harm to self or others
*
Yes
No
If yes, please explain
Your answer
Independent personal care and grooming
*
Yes
No
With assistance from care provider
Appropriate behavior with others
*
Yes
No
Other:
Appropriate behavior when in public
*
Yes
No
Other:
Appropriate behavior with the opposite sex
*
Yes
No
Need for supervision
*
Can be left alone
1
2
3
4
5
Needs constant supervision
Listens to and follows directions
*
Never
1
2
3
4
5
Always
Applicant is able to (check all that apply)
Read
Write
Tell Time
Handle Money
Can express needs and desires clearly (if nonverbal, though alternate means)
*
Cannot express needs and desires clearly
1
2
3
4
5
Can fully express needs and desires
Who is completing this application?
*
Applicant is completing this form for his/herself
Parent/caregiver is completing the form on behalf of the applicant
Other:
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Independence Through GRACE Foundation.
Report Abuse
Forms
