Day Program Application
(Please submit a $25 application fee with your application. All clients are accepted regardless of ability.)
Please give us the applicant First and Last Name:
Please give us the guardian First and Last name(s):
Contact Information for Guardian:
Email for Guardian:
Diagnosis of Individual:
Accomodations, fears, triggers, or important information that will help us care for your loved one:
Is the individual on HCS or another Waiver Program? If so, please provide the Provider, Case Manager, and Phone Number:
Do you agree to: Altruistic transporting the individual listed above to activities? (Understanding Altruistic carries full coverage insurance on all vehicles.)
Do you agree to: Altruistic taking photos of the individual listed above for organizational use including but not limited to social media posts? (no last names will EVER be used)
In case of an emergency, Altruistic staff will first attempt to contact the Guardian. If unreachable immediately, Altruistic staff will use their best judgement on seeking medical treatment and only after direct medical advice from Doctors, will Altruistic be allowed to make medical decisions that will protect the individual listed above.
Please let us know anything else that we might need to better assist your family:
Never submit passwords through Google Forms.
This form was created inside of Altruistic.
Terms of Service