Uncategorized Adult Services Intake Form Adult Services Intake Step 1 of 4 25% Name of the person signing up for Adult Services* First Last Date of Birth MM slash DD slash YYYY Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Cell PhoneEmail* Preferred Method of ContactEmailHome PhoneCell PhoneName of Parent/Guardian First Last Phone number Parent/GuardianEmail of Parent/Guardian How can we support you?What is your major concern right now?How can our team best support you?How did you learn about our programs? Tell us about yourself.What are your hobbies, special interests, and skills? Do you receive support from a local agency? If so, please tell us more about the support you receive. Do you have a known diagnosis or a disability? Please tell us more. Do you require any accommodations for participating with SNSC?Which of these do you identify as? (Check all that apply) Indigenous Asian Black or African American Native Hawaiian or Other Pacific Islander Hispanic Middle Eastern White Other Declaration & PermissionsYes,* I hereby give my permission for Special Needs Support Center to collect and store my personal information. Yes,* I confirm that I want to enroll in SNSC's Adult Services and Programs. Yes,* I understand that my personal information may be shared with team members at Special Needs Support Center if necessary. Yes,* I consent to the unrestricted use by the Special Needs Support Center (SNSC) of photographs taken, in whole or in part, unlimited use, for all purposes in any form or medium, including its use through or on any electronic media, including the internet. I also consent to the unrestricted use by SNSC of any corresponding text or audio associated with the pictures. I waive any right to inspect or approve the finished product or products that may be used with the finished photograph(s), including any narrative text that may go along with the photograph. I hereby release SNSC from any and all claims in connection with the photograph(s) and/or corresponding text or audio, including any and all claims of libel. No, I do not consent to the use of my photographs by the Special Needs Support Center. March 4, 2021/by Kendra LaRoche https://snsc-uv.org/wp-content/uploads/high-res-logo-300x200.png 0 0 Kendra LaRoche https://snsc-uv.org/wp-content/uploads/high-res-logo-300x200.png Kendra LaRoche2021-03-04 21:38:592021-03-04 21:38:59Adult Services Intake Form
