The Village Membership Application Form
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Today's Date: *
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Name of Registrant (First, Last): *
Address of Registrant: *
Registrant Date of Birth: (DD/MM/YYY) *
Registrant Contact (Home Phone &/or Cell Phone): *
Email Address and/or Registrant's Email Address: *
Gender: *
Emergency Contact Name: *
Emergency Contact Relationship: *
Emergency Contact Phone Number: *
Does Registrant have reliable transportation? If yes, please describe how they will get to and from our program locations: *
Primary Caregiver: *
Current Residential Situation: *
Developmental Diagnosis: (Please Describe if yes) *
What additional support will the Registrant require? (e.g. personal care, accessibility, feeding, increased staff ratios) *
Is the Registrant taking medications? *
Does the Registrant have any allergies or food sensitivities? Please describe: *
Is there a history of behaviour concerns? *
Required
Please describe behaviour concerns in detail. Put N/A if there are none: *
Does the Registrant have a history of Mental Health Concerns? If yes, please explain. *
What does the Registrant hope to achieve by coming to The Village? (Purpose and goals, etc): *
What staffing ratio/level is required for the Registrant at The Village, in the community and in a vehicle with other participants? Please explain if more than 1:5: *
Does the Registrant exhibit any agitation or anxiety in group settings? If yes, please explain: *
Does the Registrant want to participate in Virtual Programs or In Person Programs? *
Name of person filling out form: *
Thank you for your application! We will be in touch shortly with more information. We may require a Personal Support Indicator Form to be filled out and a Consent for Service form as well. If you have any questions you can reach us at:
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