Jam Club Registration 2018-2019 Season
Last Name *
Your answer
Student First Name *
Your answer
Student Birthdate *
mm/dd/yyyy
Your answer
School *
Your answer
Grade in fall 2017 *
Your answer
Primary Special Needs Diagnosis *
Your answer
Which Jam Club Class would you like your student to attend (please see website for class details and requirements)
Please describe your student's verbal skills
What kind of help does your student need to complete a task? *
If your student requires one to one assistance, will you or an assistant be joining us for class? *
It is OK if you or an assistant cannot attend class with your student. We are asking this question to make sure that we have enough helpers so that your student is successful in class and has fun!
Describe your student's mobility *
What is the smallest thing on this list that your student can grip independently? *
Approximate. Please don't take the time to find all of these things and test your student!
How does your student express happiness? *
Check all that apply
Required
How does your student express displeasure or pain? *
Please check all that apply
Required
Please describe your student's verbal skills - check all that apply *
Required
Is there anything else you'd like to tell us that might help us help your student succeed?
Your answer
Parent Last Name *
Your answer
Parent First Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Home phone number *
Your answer
Parent Cell Phone number *
Your answer
Best email to reach you *
Your answer
Student Email
Your answer
My student will be accompanied by a care giver. Please give us the name of the care giver.
(Skip if this does note apply)
Your answer
Payment Information *
MVYSO's Jam Club has been approved by WA State Developmental Disabilities Administration (DDA) as a respite provider. Your student's camp tuition may be covered by DDA. If you would like us to bill DDA, we will need you to sign an authorization form on your first day of Jam Club.
Regarding Jam Club payments and billing DDA *
I understand that any costs not covered by DDA are my responsibility. I understand that should payment be denied to MVYSO, I will be required to cover the cost to MVYSO payable within 30 days of the denial. I understand that should payments for Jam Club become a hardship for our family, I may apply for tuition assistance from MVYSO.
Required
Caseworker's name (skip if you are paying out of pocket)
Your answer
Caseworker's Email (skip if you are paying out of pocket)
Your answer
Caseworker's phone number
Your answer
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