The Garden Foundation Application Form
Do you think The Garden Foundation could help your loved one bloom? Please fill out the information below and we will contact you based on our openings. Thank you!
Email address *
First Name (of applicant): *
Your answer
Last Name (of applicant): *
Your answer
Address: *
Your answer
Age (of applicant): *
Your answer
Date of Birth (of applicant): *
Your answer
Gender (of applicant): *
First Name, Last Name, Relationship to Applicant: *
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Phone Number (of primary caregiver): *
Your answer
Please explain diagnosis and/or description of disability: *
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Is your loved one currently enrolled or involved in any other programs, therapies, schools or services? If yes, please list. *
Your answer
Please check all that your loved one DOES need assistance with: *
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Please list any other assistance that is needed: *
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Does your loved one have any behavior concerns? *
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How does your loved one communicate? *
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What are their hobbies and interests? *
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What special equipment or devices does your loved one utilize? *
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Does your loved one take any medication(s)? *
If yes, is all medication administered at home? *
What are your and your loved one's goals? *
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What specific services are you interested in your loved one receiving? *
Required
Is there any additional type of extracurricular or educational class that you would like your loved one to have access to? *
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Any additional comments or questions:
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How did you hear about us? *
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