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Complete the following for the participant.

	Participant Information
First Name
Last Name
Date of Birth
Street Address
City/State/Zip Code

Participant Gender *

Who does the participant live with? *

Select the programs you are interested in the participant attending: *

Complete the following for Parent/Guardian #1

	Parent/Guardian #1 Information
Name
Relationship to Participant
Primary Phone Number
Alternate Phone Number
Email

Complete the following for Parent/Guardian #2

	Parent/Guardian #2 Information
Name
Relationship to Participant
Primary Phone Number
Alternate Phone Number
Email

Are there siblings or other significant family members in the home? *

Yes

If Yes, please include name, gender, age, and relationship to applicant.

School Information

Name of current school? *

Is the student in a special education program? *

Yes

What kinds of special services, if any, does the participant receive in school? Check all that apply *

Health/Medical Information

Is the participant currently taking any medications? If so, please list including dose and time taken. *

What is the participant's current/most recent diagnosis? Who made the diagnosis? *

Please list any of the participant's significant health conditions. *

Please list any of the participant's allergies. *

Please list any of the participant's special diet/food restrictions. *

Please list any of the participant's physical limitations. *

Please describe any behavioral difficulties that the participant has (e.g. hitting, biting, self-injurious behaviors, etc.). Please be specific. Withholding information may hinder our ability to handle any crises or challenging situations. *

Other Important Information About the Participant

What special interests and strengths does the particpant have? *

What are the participant's current areas of need or challenges? *

What has been done so far to try to meet the needs of the participant? *

Does the participant receive any additional services outside of school? *

Does the participant know his/her diagnosis? How do you manage this in your family? *

Please add anything else you think we should know about the participant. *

Document Upload (All Applications)

Participant photo *

List of Allowed file types

Document Upload (For Applications to Educational/Therapeutic Programs Only)

Participant's IEP

List of Allowed file types

Participant's Neurological/Psychological Evaluation

List of Allowed file types

Additional Document #1 (Any other document you feel would be helpful to us in making our decision)

Additional Document #2

List of Allowed file types

Family Photo

List of Allowed file types

Parent/Guardian 1

I hereby make an application for the participant to attend an Ivymount Outreach Program. I have filled out all of the information to the best of my knowledge. I acknowledge that submission of this application does not guarantee acceptance into an Ivymount Outreach Program.

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Parent/Guardian 2

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Please note that applications for educational/therapeutic programs require a $50 non-refundable processing fee.

Thank you for registering. Click "Submit" below to complete your application. Someone will be in touch soon to discuss your application and payment of the processing fee.

Outreach New Participant Application