Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Applicant Lives

On Own

With Parents/Guardian

Group Home

Applicant Wishes To Attend

Full Time

Part Time

Days Requested

Monday

Tuesday

Wednesday

Thursday

Friday

Applicant Wishes to Participate in

Check all that apply

Community Engagement

Living Skills

Fitness

Literacy

Social Opportunities

OWLS (Social/Respite)

Attended From

MM

DD

YYYY

Attended To

MM

DD

YYYY

From

MM

DD

YYYY

To

MM

DD

YYYY

Is One-to-One Support Worker Required?

Please note: COED does not supply One-to-One Support Workers

Yes

No

Is Applicant Able to Participate In Out of School and/or Out of Town Excursions?

Yes

No

Phone

(###)

###

####

Any criminal convictions

No

Yes

Are there any criminal charges pending?

No

Yes

Parent/Caregiver

If applicable

First Name

Last Name