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First Name
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Last Name
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Date of Birth
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DD
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YYYY
Street Address
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City
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Postal Code
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Email Address
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Contact Number
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Applicant Lives:
On Own
Parent/Guardian
Group Home
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Applicant Wishes to Attend
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Full Time
Part Time
Number of Day Requested
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Applicant Wishes to Participate in:
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Community Engagement
Living Skills
Fitness
Literacy
Social Opportunities
Other (Please List)
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Other
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When Are You Wanting to Start
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Please Describe Applicant's Likes
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Please Describe Applicant's Dislikes
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Level of Support
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Low Needs – Very independent
Medium Needs – Mostly independent but requires some assistance/attention at times
High Needs – Requires frequent assistance/attention
One-on-One Support – Assistance needed constantly
(QVSS can only provide One-to-One Support Workers when available)
Other Pertinent Information
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Physical Limitations
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How Did You Find Us
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