Application for Intellectually Disabled
VOCATIONAL PROGRAM ADMISSION
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PERSONAL INFORMATION
(Participant Information)
Full Name: *
Date of Birth: *
MM
/
DD
/
YYYY
Address: *
Phone Number: *
Height: *
Weight: *
Sex: *
Marital Status: *
FAMILY HISTORY
Father's Name: *
Home Address: *
Occupation and Name of Employer: *
Home Phone Number: *
Business Phone Number: *
Mother's Name: *
Home Address: *
Occupation and Name of Employer: *
Home Phone Number: *
Business hone Number: *
Religious Affiliation of Applicant: *
How did you hear about us? *
Required
SCHOOLS OR PROGRAMS ATTENDED
Check all situations in which the applicant has participated *
Required
PERSONAL APTITUDE AND INTERESTS 
Describe the applicant in relation to the following areas
Diagnosis: *
General Health: *
Special Medical Problems: *
Motor Abilities:  *
Peer Relationships: *
Daily Routine/Activities *
Leisure Activities *
Specific Aptitudes and Interests (woodcraft, hand crafts, etc.): *
Special Handicaps and Disabilities: *
Please describe any activity area and/or situations that the applicant strongly dislikes: *
Please describe your goals and expectations for the applicant and what you hope that the House of the Sycamore Tree can accomplish: *
FUNCTIONAL LIMITATION AREAS
A. SELF CARE: Applicant often needs the help of another person or a mechanical device, or takes a long time, to take care of:
Personal hygiene- toileting, washing and bathing, tooth brushing *
Grooming- dressing, undressing, hair and nail care, overall *
Feeding- eating/drinking, use of utensils, chewing, swallowing  *
Needs to be prompted to take care of personal hygiene, grooming or feeding *
FUNCTIONAL LIMITATIONS AREAS
B. RECEPTIVE AND EXPRESSIVE LANGUAGE: Applicant needs daily assistance from another person, or a person with special skill (such as sign language) or mechanical device to communicate (verbally or non-verbally):
Expressive: Has difficulty speaking intelligibly  *
Has difficulty sharing information or communicating wants or needs *
Receptive: Has difficulty hearing (without a hearing aid) *
Has difficulty understanding an ordinary conversation *
FUNCTIONAL LIMITATION AREAS
C. LEARNING: Applicant needs special assistance to aid learning. The applicant may be unable, or very limited in their ability, even with special intervention, to acquire knowledge or to transfer knowledge or skills to new situations. The applicant may have difficulties with:
Cognition- recognition of persons, places, events, or objects  *
Retention- short and/or long term memory  *
Reasoning- abbility to grasp concepts, to perceive "cause and effect" relationships, ability to generalize information and skills from one situation to another *
Academic Skills- reading and/or writing, numerical concepts (arithmetic, money and value of objects) *
FUNCTIONAL LIMITATION AREAS
D. MOBILITY: Applicant needs the assistance of another person or a mechanical device, or takes a long time, or requires a barrier-free environment, in moving from place to placein their home or community. 
NOTE: This does not refer to the ability to operate motor vehicles or use public transportation.
Applicant needs or uses crutches, walker, or wheelchair for mobility *
Applicant walks independently, but takes a long time to due to gait and/or coordination difficulties *
Applicant requires assistance in performing activities requiring manual dexterity, fine motor control, or eye-hand coordination, such as using locks, appliances, or light switches *
FUNCTIONAL LIMITATION AREAS
E. BEHAVIORAL: Please describe in detail
Self abusive *
Passive *
Aggressive *
Verbal hostility *
Appropriately assertive *
States wants and needs *
Oriented to time and place *
Hyperactive *
Self-stimulatory behaviors *
Inappropriate sexual behavior *
Accepts responsibility for own actions *
CRIMINAL HISTORY
Has applicant had any criminal charges or convictions? *
If yes, please describe. If no, please type n/a *
MEDICAL HISTORY
If their are medical factors that would influence the care, health and well being of this applicant, please explain:  *
I affirm that the preceding information is, to the best of my knowledge and belief, a complete and true statement of facts and circumstances relative to this application *
Required
Name of Parent/Guardian and date (MM/DD/YYYY): *
Name of Applicant (If appropriate) and date (MM/DD/YYYY):
Name of person filling out application if other than parent or guardian and date (MM/DD/YYYY):
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