Virtual Program Application

Some of our classes are also offered online through Zoom! If your student is interested ONLY in virtual classes, please complete the application form below. After we have processed your submission, you will receive an email with an explanation of how to register for classes. Thank you!

Name*
First Last
Name of the participant (child)
Parent Name*
First Last
Name of Parent/Guardian
Parent Phone*
Parent or Guardian Phone
Email*

Please enter the PRIMARY email address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Do you have legal guardianship of Participant?*
Does Participant live with you?*
If no, please explain.
Gender*
Gender of child (for grant reporting only)
Date of Birth*
MM slash DD slash YYYY

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*
- Caucasion
- 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 attending (if any)
Other Info
Any other information which would be helpful to ensure participant’s enjoyment?
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
- Virtual On-Line Programming
Please check all IC programs your child might be interested in participating in.
Waiver*
- I have read and understand the Waiver Statement above.
You must accept the IC Waiver to be considered for participation.
You can view the IC Waiver in a new window.
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VIRTUAL PROGRAM

Virtual Program Application

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