ITG GRACE Program Application
Please read all questions carefully and answer to the best of your knowledge. Once this form is submitted, a GRACE team member will be in touch.
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Email *
Prospective candidate will at minimum, fulfill the following criteria:

  • 18 years of age or older (admission process may begin earlier)
  • Have a primary diagnosis of developmental disability or cognitive challenge
  • Be accepting of supervision
  • Capable of self-care and activities of daily living or provide caregiver if unable to do so (women must take care of monthly menstruation needs or remain at home)
  • Able to ambulate and/or transfer independently (provide care staff if unable to do so)
  • Free of impulse to take flight or run away
  • All medical conditions must be manageable
  • Free of communicable diseases
  • Free from patterns of aggression or abuse toward self and others
  • Able to participate successfully in community with others, and engage in programs and activities to the extent of his/her ability
  • Provide two letters of recommendation (previous school, current program, family/friend or home church.)

Name of Applicant *
Full name of prospective participant. May also include preferred name / nickname
Phone Number *
Phone number above is... *
Address *
Gender *
Date of Birth *
Primary Disability
Physical disability(s)
Medical conditions
Medications taken
Please check any devices used
Are there any things/situations that cause anxiety?
Controls temper *
History of harm to self or others *
If yes, please explain
Independent personal care and grooming *
Appropriate behavior with others *
Appropriate behavior when in public *
Appropriate behavior with the opposite sex *
Need for supervision *
Can be left alone
Needs constant supervision
Listens to and follows directions *
Applicant is able to (check all that apply)
Can express needs and desires clearly (if nonverbal, though alternate means) *
Cannot express needs and desires clearly
Can fully express needs and desires
Who is completing this application? *
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