Afternoon Club Signup Form Personal InformationName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)School / Employer Grade / Program Please indicate the presence of a developmental disability, if any (check all that apply): Autism Epilepsy/Seizure Disorder Intellectual Disability Learning Disability (e.g., dyslexia, dysgraphia) Other Neurological Impairment Undetermined Developmental Disability Other Pls indicate disability Does the applicant have care coordination? Yes No To help us best accommodate the applicant, please answer the following questions as accurately as possible.What level of support is needed for the applicant to be successful? Shared Support 1:1 Support Other Does the applicant require the assistance of an aide for personal care or management needs? Yes, 1:1 aide Yes, shared No I understand that C-HOPE cannot provide assistance for personal care needs such as toileting and eating. Did/does the applicant have a Behavior Intervention Plan (BIP)? Yes No How does the applicant communicate? Check all that apply. Verbal - carries on full conversations. Are there articulation challenges? Verbal - carries on limited conversations. Articulation challenges? Echolalia (repeats words and/or phrases) Sign Language (ASL or Signed Exact English) Gestures (other than sign language) Augmentative/Assistive Technology - high tech Augmentative/Assistive Technology - low tech Others Please indicate Which best describes the applicant's physical abilities? Ambulatory Ambulatory with assistance Wheelchair user Does the applicant have any allergies? (e.g., medication, food, bee stings, latex, etc.) Yes No If yes, please provide detail Is an EpiPen required for any allergy? Yes No If yes, please provide detail Please list any dietary restrictions the applicant may have.In the event of a serious emergency (e.g., fire), what is the most critical piece of information about the applicant do you want us to share with first responders? Is the applicant fearful of or adverse to any of the following? Check all that apply and provide detail. Loud noises Animals/Insects Textures Siren/Fire Alarm Police/Firefighter/EMT/Paramedic Other None of the above Please indicate Do any of the following frustrate the applicant? Check all that apply and provide detail, as necessary. Noise Raised voices Touch/Touching Bright lights Cold temperature Hot temperature Other None of the above Please indicate Are there any key words, phrases, or other stimuli that should or should not be used with or around the applicant? Please list requested accommodations. C-HOPE willl consider requests as program limitations allow.Please list interests and hobbies of the applicant.In order to maximize the applicant's experience in this program, please provide additional information that would be valuable for C-HOPE staff to know.PARENT / GUARDIAN INFORMATIONName(Required) First Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code EMERGENCY CONTACT INFORMATIONContact #1Name(Required) First Last Relationship to the applicant Cellphone(Required)Home PhonePermission I give permission to Contact #1 to pick up applicant Contact #2Name(Required) First Last Relationship to the applicant Cellphone(Required)Home PhonePermission I give permission to Contact #1 to pick up applicant Please be sure to include the following with your application: Program application $25 non-refundable deposit (checks payable to C-HOPE Inc.) Consent/Release forms Medication self-carry/administer documentation, if applicable NameThis field is for validation purposes and should be left unchanged.