Learning-4-Life

A Skills Development and Recreation Program for Adults with Disabilities

Program Application

The information below is requested to help Program staff better support participants registering for the Learning-4-Life Program. Please complete as much as you feel comfortable sharing. This information will not be shared beyond the activity location/space.

Participant Information Date Received (Office Use Only): ______
Last Name / Given Name(s)
Street Address Apt. / City or Town / Province
Postal Code / Date of Birth / Telephone (Home) / Telephone (Cell)
Email Address / Health Card Number
Person Completing this Form (if applicable) / Relationship
Emergency Contact Information
Name of Emergency Contact # 1 / Relationship
Telephone (Home) / Telephone (Work) / Telephone (Cell)
Name of Emergency Contact # 2 / Relationship
Telephone (Home) / Telephone (Work) / Telephone (Cell)

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Desired Program Day(s) and Support
Mon / Tues / Wed / Thurs / Fri
Please check Program day(s) requesting / (Office Use Only)
Requested Program Days ______
Total Fee Per Week
$______
Please indicate whether you will be providing your own support or require support on behalf of Learning-4-Life Program staff. / Own Support / Own Support / Own Support / Own Support / Own Support
WindReach
Support / WindReach
Support / WindReach
Support / WindReach
Support / WindReach
Support

For participants who wish to provide their own support or must provide their own support because they require a lower than 1:4 staff-to-client ratio, a $30.00 per day Activity Fee applies. For participants who are able to fully participate in the Program with the assistance of a 1:4 staff-to-client ratio, a $100.00 per day fee applies (Activity Fee $30 + Basic Support Fee $70).

Medical Information
Do you have any health-related concerns that may impact the type of support you will require within the Learning-4-Life Program (i.e., seizures, hearing difficulties, vision difficulties, etc.)? / Yes / No
If yes, please specify:
What is the state of your overall physical health? / Excellent / Good / Average / Fair / Poor
Do you have any allergies or sensitivities? / Yes / No
If yes, please specify:
Are you able to administer your own medication during Program hours if required?
* Please note that Program staff does not dispense medication during Program hours. / Yes / No
General Information and Interests
What kind of support might you require while attending the Learning-4-Life Program (i.e., reminders to use the bathroom, use of appropriate language, positive problem-solving skills, etc)?
What is your preferred method of communication (i.e., symbols/pictures, communication device, gestures, oral, etc.)?
Do you require support at meal times (i.e., limited intake, avoidance of certain foods, assistance eating, etc.)? / Yes / No
If yes, please specify:
As a public facility and functioning farm, WindReach Farm often has large groups of visitors and various farm animals located throughout its property. Please describe any social concerns or situations you might find challenging while participating in the Learning-4-Life Program.
In the event that you experience a challenging situation while participating in the Learning-4-Life Program, how can Program staff best support you?
What are some of your interests and/or hobbies?
What goals or areas of development would you like to work on while attending the Learning-4-Life Program?
Is there anything else you would like Program staff to know that may help you be successful in the Learning-4-Life Program?
Transportation Information
Please outline your transportation schedule to and from WindReach Farm:
Durham Region Transit (DRT)  / Taxi  / Parent/Guardian  / Other  ______
Individual(s) authorized to drop-off and pick you up from the Learning-4-Life Program:
1. ______Relationship: ______
2. ______Relationship: ______
3. ______Relationship: ______
Please Note!
To ensure that all participants actively engage in and enjoy the Program, individuals who require a lower than 1:4 staff-to-client ratio and/or with the following exceptionalities must be accompanied by a support person or caregiver provided and paid for by the individual, family or outside organization:
  • Medically Fragile – g tubes, trachea tubes, requiring suction, etc.
  • Physically Unable to feed, transfer, perform personal hygiene, etc.
  • Behavioural/Aggressive – Physically or verbally
While the Living-4-Life Program strives to accommodate Program participants, WindReach Farm is a public facility and; therefore, reserves the right to remove any participant from the Program who poses a potential danger/risk to staff, volunteers, visitors, or fellow Program participants.
I have completed this Learning-4-Life Program application form accurately and truthfully to the best of my knowledge.
______
(Signature of Participant or Parent/Guardian/Next of Kin) (Date)
I, ______, hereby give the staff and volunteers at WindReach Farm permission to
(Print Name)
use theinformation provided within this application form for programming and service delivery.
______
(Signature of Participant or Parent/Guardian/Next of Kin) (Date)
______
(Name of Witness) (Date)
______
(Signature of Witness) (Date)

Please email/mail this application form to the Adult Day Services Coordinator, Vanessa Slater, at: WindReach Farm

312 Townline Road

Ashburn, Ontario

L0B 1A0

Thank you for choosing WindReach Farm. The Adult Day Services Coordinator will contact you to schedule a Learning-4-Life Program intake interview within 14 days of receiving your application.

Learning-4-Life Program Application Form 1