Application Form

"*" indicates required fields

Step 1 of 5 – Basic Information

Company

This field is for validation purposes and should be left unchanged.

Email Address:*

How did you hear about IF Ambassasdors?*

Participant's Name:*

Participant's Date of birth:*

Participant's UCI Number:

What is the participant's regional center?*

Westside Regional Center

North Los Angeles County Regional Center

South Central Regional Center

Eastern Los Angeles Regional Center

Other

What is the participant's Regional Center Service Coordinator's name and contact information?*

Parent/Conservator #1 Name:*

(enter n/a if not applicable)

Parent/Conservator #1 Phone Number:*

(enter n/a if not applicable)

Parent/Conservator #2 Name:

Parent/Conservator #2 Phone Number:

Home Address:*

Street Address City State ZIP Code

Home Address #2 (if applicable):

Street Address City State ZIP Code

What is the name of the school that the participant attends?*

What school grade is the participant in?*

What services are the participant currently receiving from Regional Center?*

Please include number of hours/session per month.

What health insurance does the participant have? Does the participant have Medi-Cal?*

Are there any medical services that the participant, care team, or you believe they can benefit from that they are not currently receiving?

Is the participant receiving services from school? If so, what services and how long are the sessions?*

Is the participant receiving IHSS? If so, do they have protective supervision?*

What do you admire about your child?*

Does the participant have any siblings? If so, how many and what are their ages?*

Does the participant have any pets? If yes, how many and what kind of animal?*

What are your child's likes (activities, food, etc.)?*

What are your child's dislikes?*

What are your child's strengths?*

What is important TO your child? What matters most to ensure happiness, comfortability, and fulfillment?*

What is important FOR your child? What issues affect health, safety, and activities of daily living?*

What community activities does your child like to participate in now?

What community activities does your child want to one day participate in the future?

What are some barriers or challenges that your child has encountered in his life?*

(i.e. parents both work full time and cannot take the child to sessions, no reliable transportation)

When your child is having a bad day, what are ways to help him calm down or feel better?*

What is helpful for your child (home, school, or community)?*

What is not helpful for your child (home, school, or community)?*

List family members who are involved in your child's life.*

List friends who are involved in your child's life.

List service providers who are involved in your child's life.

(i.e. teachers, paid staff, case managers, therapists, coaches)

List community members who are involved in your child's life.

(i.e. neighbors, spiritual leaders, coworkers)

Describe a weekday schedule in your child's life from when they wake up to when they go to bed.*

(detail by day and hour; i.e. school, meals, aftercare)

Describe a weekend schedule in your child's life from when they wake up to when they go to bed.*

(detail by day and hour; i.e. sports, meals, park)

Describe characteristics of people your child gravitates towards.*

Describe characteristics of people your child avoids.*

Describe situations that encourage communication from your child.*

What behaviors does your child do to communicate?*

(i.e. vocal stims, points)

What do you think your child is trying to communicate?

What should people do to respond to the communication?*