Program Interest Form-Exceptional Humans
We are so glad you are interested in our programs!
Applicants must meet the following criteria:

● Demonstrates basic communication skills;
● Motivated to learn skills to increase independence;
● Possess sufficient emotional maturity and stability to participate in all aspects of the program;
● Demonstrate the ability to accept and follow reasonable rules and expectations;
● Interact respectfully with peers and staff;
● Capable of maintaining behavior which does not impede oneself or others from fully
participating in all aspects of community activities; and
● Does not pose a danger to oneself or others.

Exceptional Humans reviews all program interest forms for applicants meeting the above criteria regardless of socioeconomic status, race, gender, sexual orientation, religion, or national origin.
If you require a printed copy or have any questions concerning our programs, please
email kelly@excpetional-humans.org


Once the program interest form is submitted, a director will reach out to request additional information for review prior to scheduling and initial informational meeting.
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Email *
Name of Scholar (First, Middle Initial, Last) *
Scholar Date of Birth *
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Parent or Guardian Name: *
Contact Information
Home Address (Street, City, State, Zip Code): *
County of Residence *
Scholar Phone Number (when applicable):
Parent/Guardian Phone Number: *
Scholar Email Address (when applicable):
Parent/Guardian Email Address: *
Service and Support Information
Please complete this section if you have a Service Coordinator.
Name of Service Coordinator:
Service Coordinator Phone Number:
Service Coordinator Email Address:
Funding Source
Payment will occur through which of the following: *
Date Ready To Begin Services: *
MM
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DD
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YYYY
Service(s)
Services interested in learning more about: *
Required
Personal History
What school do you/did you attend? *
If you have transitioned out of school, when did this occur? *
If you are or you have been employed, provide the employers name(s) and date(s) of employment.
If you have left a job, provide the reason.
Have you received community integration or employment services before? *
If yes, please list the agency where you received services and when you received services.
If yes, please share the reasons to transfer:
Please share what a current day in your life entails. *
Please list three of your favorite things to do. *
Thank you for completing the Program Interest Form.  One of our Directors will be in touch within one week.  
A copy of your responses will be emailed to the address you provided.
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