PROGRAM TUITION OPTIONS *

I will use my DDD Budget for the 60 hours workshop series under Community Based Services (CBS)

Private Pay

Scholarship option for those needing financial assistance

Do you have a disability? *

Yes

No

Are you your own Guardian? *

Yes

No

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Name *

First Name

Last Name

Phone *

(###)

###

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I do the following tasks on my own, without assistance: *

(Please choose all that apply)

I independently make responsible decisions

I independently go grocery shopping

I independently cook meals for myself or my family

I independently clean my room

I independently sort, wash, fold and put away laundry

I independently set goals and work on goals daily

I independently use a daily planner

I independently self-advocate for my wants and needs

I independently stay home alone overnight in my home

I independently arrange for and use a form of transportation

I independently read

I independently write

I independently use the restroom facilities

I independently feed myself

As the Participant, I commit to: *

(Please choose all that apply)

Attending all LMBL sessions

Plan transportation to arrive and depart on time

Fully participate in this workshop series

I require accommodations or assistance *

Yes

No

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

As the Parent or Guardian, I have reviewed the scheduled dates and I commit to: *

Attend the Zoom Orientation

Attend the Midway Meeting in person

Attend the Final Celebration Dinner in person