Please note, we only serve ages 13 and up. Enrollment Waitlist Please complete the following information to add your student to the waitlist. CommentsThis field is for validation purposes and should be left unchanged.Parent/Guardian Name(Required) First Last Student Name(Required) First Last Consent(Required)We do not accept students younger than 13. Please check this box to confirm your inquiry is for a person at least 13 years old. Younger students will not be added to the wait list. My student is at least 13 years old.Student's Age(Required)Please note that we only accept students who are 13+.At this time we accept the HCS Medicaid Waiver program and private pay only.(Required)We are unable to bill private insurance or Medicaid/Medicare for services. We only accept HCS Medicaid Waivers and private pay at this time. My student has a HCS Medicaid Waiver and an agency will be paying for services We do NOT have an agency but I’m interested in paying privately We are still on the waiting list for the waiver program Assigned Level of Need(Required)Please select your student’s assigned level of need issued by their agency. If they have not been issued a LON, select NONE. If you are unsure, select the UNKNOWN option. 1 5 8 6 None I don’t know What is your student's mobility?(Required) Walks independently Uses wheelchair/stroller full-time Needs wheelchair/stroller for long distances Uses walker for assistance Does student have a history of elopement (bolting or running away)?(Required) Yes No Elopement History(Required)Please describe any history of wandering or escaping. Does student require assistance with toileting?(Required)If yes, please explain further. Yes No Toileting Assistance(Required)Please describe toileting assistance needs. Does student require assistance with feeding?(Required)If yes, please explain further. Yes No Feeding Assistance(Required)Please describe feeding needs.Phone(Required)Please provide the best number to reach you.Email(Required)We will use this email to send confirmations about your application. Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Please tell us about your student's needs or behaviors.(Required)
