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HELPING INDIVIDUALS REACH THEIR HIGHEST POTENTIAL

2019-2020 SCHOOL YEAR

REGISTRATION FORM

 
Participant name *
Participant name
Birthday *
Birthday
Release time *
Release time
Primary address *
Primary address
Secondary address
Secondary address
Primary phone *
Primary phone
Secondary phone
Secondary phone
Please fill out the information below if the child is still under the guardianship of their parent(s), but currently resides in a foster home of which they are receiving their primary care:
Foster parent name(s)
Foster parent name(s)
Move-in date
Move-in date
Potential long-term arrangement?
Address listed above?
If no, foster home address:
If no, foster home address:
GROUP PROGRAM REGISTRATION PERIODS
To better accommodate our programming and prepare our team for incoming participants and families, we now have registration periods for our group programs. It is important that you note the registration deadline and its corresponding start date as this will determine when your child will begin attending the program.
DEADLINE: September 3, 2019 PARTICIPANT START DATE: Week of September 9, 2019
DEADLINE: October 7, 2019 PARTICIPANT START DATE: Week of November 4, 2019
DEADLINE: DECEMBER 9, 2019 PARTICIPANT START DATE: Week of JANUARY 6, 2020
DEADLINE: February 10, 2020 PARTICIPANT START DATE: Week of March 8, 2020
DEADLINE: April 12, 2020 PARTICIPANT START DATE: Week of May 10, 2020
PARTICIPATION DAYS
Please indicate from the list below which days you’d like your child to attend. NEW CHANGE from previous years, the program ends at 6:30 p.m. Monday-Thursday and 7:30 p.m. on Fridays. Please see attached Parent Handbook with Daily Focus descriptions to best choose participation days for your child.
DAY OF PARTICIPATION *
Brightwheel is our main source of communication with parents and guardians. You can find more information on this resource in our Parent Handbook. Please contact us with any questions regarding this resource.
COUNTY CONTACT
Prior to turning in your child’s registration form, we highly encourage you to contact your county case manager for approval of the service hours listed above. Without approval, we cannot guarantee that your child will have the allotted hours available in their budget to participate in all registered days. ADDITIONALLY – We must receive an updated authorization for services from your child’s caseworker prior to the start of services (even if they have been receiving ongoing services). If we have not received an authorization of services prior to the indicated program start date (listed above,) we will be unable to provide the services registered for until we have received the authorization. Once the authorization is received, your child will be on the schedule the following Monday. We highly encourage you to be in contact with your county caseworker to ensure there is no lapse in services.
Please indicate if you have received approval from your county case manager
GROUP PROGRAM MEDICATIONS *
Will ABLE need to administer prescribed medications to your child during their participation?
If medications will need to be given, a letter and form will be sent out for you to complete prior to your child starting group program services. Please inform your child’s ABLE Program Director immediately if your child has any major changes to their medications.
EMERGENCY CONTACT *
EMERGENCY CONTACT
Primary phone *
Primary phone
Secondary phone
Secondary phone
ABLE APPAREL
During community outings, we find that having participants wear an ABLE t-shirt allows for us to easily identify everyone. Please indicate your child’s shirt size below so that we may have the attire available.
Please write down any information that you feel would be helpful for us to know about your child this school year. This could be new preferences, likes, dislikes, and/or medical/health updates, changes to family environments, etc.
ACKNOWLEDGMENT & AGREEMENT
Once your child has been accepted, you will be required to sign an acknowledgment/photo-release agreement with your program director.

 

 
 
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