Voice Over Application
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Email *
Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Email Address *
Phone Number *
Which Program Are You Applying to? *
Did You Have An IEP or 504 Plan in School? *
This program is conducted virtually via Zoom. Do you have a computer, camera,  and accessible internet access? *
Are you willing to attend Saturdays from 1:30pm - 3:00pm?
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Are You Currently Enrolled in College? *
Are You A Client of the Regional Center? *
Will you be using Self-Determination Funds to pay for this program? *
Name of Regional Center
Name of Service Coordinator
Service Coordinator Phone Number
Service Coordinator Email Address
Are You A Client of Department of Rehabilitation? *
Department of Rehabilitation Office Address
Name of Case Worker
Case Worker Phone Number
Case Worker Email Address
Briefly Describe Why You Want to Attend our Program *
How Did You Hear About Us? *
If accepted, you will need to place a credit card on file which will be debited on the 1st of every month in the amount of $250.00. Are you able/willing to do this? *
Do You Accept the Terms, Conditions and Privacy Policy? *
After you submit this application, a program supervisor will reach out you.  Please write the best way for us to reach you either by phone or email address. *
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