T.I.D.E. Intake Form

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Thank you for your interest in our program! We are excited to learn and have fun with you! Please reach out if you have any questions or need assistance with the intake form. After you complete it, we will reach out to schedule a time to chat.

This form will take about 5-10 minutes to complete.

Best,

Courtney Smith (founder)

Tidellc.sd@gmail.com

www.tidesd.org

Applicant's name (first & last): *

Applicant's email: *

Applicant's UCI number: *

Applicant's phone number: *

Applicant's home address (street, city, state, zip): *

Applicant's birthday: *

YYYY

Conserved? *

Yes

Supported by a Decision-Making Team

Partial

Emergency contact name: *

Relationship of emergency contact: *

Emergency contact email: *

Emergency contact phone: *

SDP FMS agency (if private paying, write "Private Pay"): *

Do you have any allergies? *

How do you get around? Do you have any transportation needs? *

What kind of services are you looking for? *

1:1

Small group (2-5 others)

Social Events

Entrepreneurial Support

Summer Activity Program

Required

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