Youth & Young Adults w/ Disabilities The Funhouse Commons’ program for youth and young adults with disabilities. Please enable JavaScript in your browser to complete this form.Participant Name *FirstLastParticipant Chosen Name or NicknameDate of Birth *GenderFemaleMaleNon-BinaryPrefer not to answerParticipant's PronounsParticipant's Phone *Participant's Email *Participant Preferred Contact Method *PhoneEmailTextParticipant's AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParticipant's Primary Contact *FirstLastThis person should be contacted for the following: (check all that apply)BillingRegistration & Class AttendanceMedical or Behavioral EmergencyRelationship to Participant *Primary Contact Phone *Primary Contact Email *Primary Contact AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary Contact Preferred Contact MethodPhoneEmailTextIs the Participant their own legal guardian?YesNoIs the Primary Contact the legal guardian?YesNoLegal Guardian Name *FirstLastLegal Guardian Relationship to ParticipantLegal Guardian Phone *Legal Guardian Email *Legal Guardian Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParticipant Language of Care (What language do you use for appointments and/or classes?)Are interpreter services required?YesNoMedical & Developmental InformationDoes the participant have any of the following services? (select all that apply)DDA (Developmental Disabilities Administration)Department of Vocational RehabilitationUnsureNot ApplicableOtherIf Other, please explain:Participant Diagnosis (select all that apply)Autism Spectrum Disorder (ASD)Down SyndromeCerebral PalsyIntellectual disabilityDevelopmental disabilityADHD/ADD (Attention-Deficit/Hyperactive Disorder)Traumatic Brain InjuryGenetic DisorderTuberous SclerosisHearing impairment or lossLearning disabilityVision impairmentDevelopmental delaysUnknownOtherIf Other, please explain:Other Psychological Diagnosis?Other Medical Diagnosis?Can the participant independently (no oversight/guidance) do any of the following? (select all that apply)Toileting routinesTransition between activitiesEat their own snackCommunicate their basic wants/needsEngage in leisure activitiesMake choicesFollow multi-step directionsDoes the participant have a history of individualized behavior interventions? (Including 1:1 supports)YesNoParticipant's current goals:Is the participant currently employed? If so, where?How will program payments be made?DDAPrivate PayScholarshipNeed AssistanceWill you need a scholarship to help pay for program fees?YesNoPlease list the first and last names of anyone who has permission to pick-up the participant:Is there anyone who is NOT ALLOWED to pick-up the participant?Is there anything else you'd like us to know?By signing this form, I declare that I am the legal guardian of the Participant listed above and am authorized to grant such permissions. I agree to hold harmless The Funhouse, it's employees, volunteers, or anyone connected with The Funhouse organization for any injury or other problems arising from participation in this program. *I AgreeBy signing this form, I understand and agree that photos/videos taken of the Participant at The Funhouse may be used by The Funhouse for promotion our programs, classes, events, in print, TV, social media or on the website.I AgreeI Do NOT AgreeSignature *Clear SignatureSubmit