Member Profile Form
Max Higbee Center serves youth and adults living with developmental disabilities.

Our programs are growing, so we are currently only accepting new members in our Healthy Lifestyles Program, Tuesdays and Thursdays 10am - 1:30pm and our After School Program, Monday - Friday 3:30pm - 5:30pm. ​If you'd like to get started in these programs, or be added to our waitlist for our other programs, we need to gather some information from you.

This information will be kept confidential and only shared with Max Higbee Center staff, volunteers, and program partners in order to ensure quality service delivery.

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Name of person filling out form: *
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Phone Number of person filling out form: *
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Email of person filling out form: *
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Participant Name: *
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Participant Birth Date: *
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Participant Address: *
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Participant City/Zip Code: *
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Participant Email: *
If you do not have access to email, please enter "n/a".
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Do you live: *
Participant Phone Number: *
If you do not have a phone, please enter "n/a".
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Are you a self-guardian? *
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