Participation Form - Inclusion Connections

Type of Application*

Please select only one!

Name*

Name of the participant (CHILD).

First Last

Parent Name*

Parent or Guardian Name

First Last

Parent Phone*

Parent or Guardian Phone

Alternate Contact Name

First Last

Alternate Contact Phone

Email*

Please enter the PRIMARY email address

Address*

Residence Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Do you have legal guardianship of Participant?*

Please provide name and email address of Participant's legal guardian.*

If participant is their own guardian, please enter their name and email address.

Does Participant live with you?*

If no, please explain.

e.g. in group home, alone, other

Gender*

Gender of Child (for grant reporting only)

Date of Birth*

CHILD's birthdate

Disability*

Autism
Cerebral Palsy
Down syndrome
Other

You may select more than one.

Other Disabilities

Please describe your child's other disabilities

Ethnicity*

Caucasian
African American - Black
Hispanic - Latino
Asian
Native American
Mixed Race

Child's ethnicity (this field is for Grant Reporting Only) You may select more than one.

Medicaid*

Is your child Medicaid Eligible? (If you are on the wait list, please answer "yes"). This is for grant reporting purposes only.

Earned Income*

Is the CHILD'S earned income above or below $12,490? This is for grant reporting purposes only.

School

School attending (if any)

Current Employer

Child's employer (if any)

Child occupation

Child's occupation (if any)

Strengths*

Participant's strengths, likes, dislikes, favorite activities, hobbies, sports, etc.

Communication*

How does participant communicate wants and needs?

Behaviors*

Behaviors or fears we need to know about when participating in group activities

Support*

How we can best support participant when exhibiting behaviors.

Safety*

Safety concerns for participant in group activities.

Aggression*

Has participant had history of aggressive behaviors? Please explain.

Wandering*

Has participant had history of wandering off? Please explain.

Activities*

What kinds of activities does participant enjoy?

Does Participant have a history of physical or verbal aggression, or outbursts or any kind?*

If yes, please explain.

Does Participant have difficulty accepting correction or following directions?*

If yes, please explain.

Does Participant have a history of destruction of property?*

If yes, please explain.

Does Participant smoke or have a history of drug or alcohol use?*

If yes, please explain.

Has participant ever been charged or convicted of a crime?*

If yes, please explain.

Does the participant have a history of sexually inappropriate behavior?*

If yes, please explain.

Medical*

List participant allergies/medical conditions.

Other Info*

Any other information which would be helpful to ensure participant's enjoyment and safety?

Programs*

Evening: fitness, cooking, art, theater, dance, music, social opportunities and more
Day: PawsAbilities skills training, pre-employment classes, and job placement - in Olathe only
Summer Camp
BelongKC independent living

Please check all IC programs your child is interested in participating in.

Waiver*

You must accept the IC Waiver to be considered for participation.
You can view the IC Waiver in a new window.

I have read and understand the Waiver Statement above.

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