RISE for Autism Teen Night Participation
-Teen nights are the first and third Friday of every month.
-Teen nights are 7:00-9:00pm
-Private pay for Teen Nights is $35

ALL PARTICIPANTS ARE SUBJECT TO REVIEW. COMPLETION OF THE APPLICATION DOES NOT GUARANTEE TEEN NIGHT APPROVAL

If you are a MD Autism Waiver client, please consider adding us to your plan of care to avoid the teen night fee.

Please send all Teen night questions/concerns to: tiservices@riseforautism.org

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Participant Information:
The following information should be answered on the participant ONLY. There will be a separate section for the caregivers.
First Name: *
Last Name: *
Date of Birth: *
MM
/
DD
/
YYYY
Age: *
Gender: *
Street Address: *
City: *
State: *
Zip Code: *
School: *
Grade: *
County: *
Diagnosis: *
Required
Other (Please specify)
Is your child able to functionally communicate via spoken language or a communication device? *
Parent/Guardian and Family Information
Parent/Guardian's Legal Name: *
Phone Number: *
Email: *
Address: (If different than child's)
Marital Status *
If divorced, who has legal custody?
Please complete the following questions if there is a second legal guardian to the participant.
Second Parent/Guardian's Legal Name (If applicable):
Email (If applicable)
Address (if different and/or applicable):
Phone Number (if applicable):
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