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The Village Application Form
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* Indicates required question
Name of Registrant (First, Last):
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Your answer
What Registration are you interested in attending?
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Your answer
Today's Date:
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MM
/
DD
/
YYYY
Address of Registrant:
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Your answer
Registrant Date of Birth: (DD/MM/YYY)
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Your answer
Registrant Contact (Home Phone &/or Cell Phone):
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Your answer
Email Address and/or Registrant's Email Address:
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Your answer
Gender:
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Male
Female
Prefer not to say
Other:
Emergency Contact Name:
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Your answer
Emergency Contact Relationship:
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Your answer
Emergency Contact Phone Number:
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Your answer
Does Registrant have reliable transportation? If yes, please describe how they will get to and from our program locations:
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Your answer
Primary Caregiver:
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Parent(s)
Self
Other:
Current Residential Situation:
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Family Home
Own Home
Relatives
Group Home
Other:
Developmental Diagnosis: (Please Describe if yes)
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Your answer
What additional support will the Registrant require? (e.g. personal care, accessibility, feeding, increased staff ratios)
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Your answer
Is the Registrant taking medications?
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Yes, needs support
Yes, self administers
No medications
Does the Registrant have any allergies or food sensitivities? Please describe:
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Your answer
Is there a history of behaviour concerns?
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Verbal Aggression
Physical Aggression
Self-injurious behaviour
Property Damage
Other:
Required
Please describe behaviour concerns in detail. Put N/A if there are none:
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Your answer
Does the Registrant have a history of Mental Health Concerns? If yes, please explain.
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Your answer
What does the Registrant hope to achieve by coming to The Village? (Purpose and goals, etc):
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Your answer
What staffing ratio/level is required for the Registrant at The Village, in the community and in a vehicle with other participants? Please explain if more than 1:5:
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Your answer
Does the Registrant exhibit any agitation or anxiety in group settings? If yes, please explain:
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Your answer
Are there any triggers for the registrant while in the community and in a vehicle? (For example, loud noises, TTC buses, etc.)
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Your answer
Does the Registrant use words to communicate?
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Uses words, full vocabulary
Uses words, medium vocabulary
Uses words, limited vocabulary
No words, but fully understands when spoken to
No words, limited understanding when spoken to
Other:
Is there any information about the registrant that will be helpful for us to know? (For example, needs assistance to buy lunch, needs extra time to eat, etc.)
Your answer
Does the Registrant want to participate in Virtual Programs or In Person Programs?
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Virtual Only
In Person Only
Able to participate in both virtual and in person programming
Name of person filling out form:
*
Your answer
Thank you for your application! We will be in touch shortly with more information. We may require a Personal Support Indicator Form to be filled out and a Consent for Service form as well. If you have any questions you can reach us at:
416-633-0614 ext. 0 or ext. 2
thevillage@christian-horizons.org
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