Application for Day Programs PARTICIPANT INFORMATIONFirst Name* Last Name* Preferred Name Date of Application* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth* MM slash DD slash YYYY Is applicant a Medicaid recipient, or eligible recipient?*Select One...Yes (If Yes, please provide number)NoMedicaid #* GenderSelect One...MaleFemaleOtherWhich Day Program are you applying for?* Charlotte Arts Center Lincolnton Arts Center Reidsville Arts Center How many days per week are you looking to attend?Please enter a number from 1 to 5.Minimum number of hours to attend per week? Maximum number of hours to attend per week? FAMILY DATAParent or Guardian First Name* Parent or Guardian Last Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Home PhoneWork PhoneCell PhoneEmergency Contact Name* Emergency Contact Relationship* Emergency Contact Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Home PhoneEmergency Contact Work PhoneEmergency Contact Cell PhoneREFERRAL DATACompany Case Manager/Contact Person Name Referral Person's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Referral Person's Email Referral Person's Main PhoneReferral Person's Relationship to ParticipantSelect One...ParentLegally Responsible PersonGuardianCase ManagerOtherOther (Please Specify) CURRENT SERVICES RECEIVEDServices Currently ReceivedPlease select all services which are currently received or approved to receive. Select All Case Management Community Support Day Activity Day Support Developmental Therapies Residential Supported Employment HiddenServices Currently ReceivedPlease select all services which are currently being received. Case Management Community Support Day Activity Day Support Developmental Therapies Residential Supported Employment DIAGNOSIS - DSM VAxis I - Primary DiagnosisClinical disorders, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders.Axis I - Primary Diagnosis 1NAMENUMBERTYPEAxis I - Diagnosis 2NAMENUMBERTYPEAxis II - Personality DisorderAxis II - Diagnosis 1NAMENUMBERTYPEAxis II - Diagnosis 2NAMENUMBERTYPEAxis III - General Medical ConditionsThese include diseases or disorders that may be related physiologically to the mental disorder; that are sufficiently severe to affect the patient's mood or functioning; or that influence the choice of medications for treating the mental disorder.Axis III - Diagnosis 1NAMENUMBERTYPEAxis III - Diagnosis 2NAMENUMBERTYPEAxis IV - Psychosocial and EnvironmentalThese include conditions or situations that influence the diagnosis, treatment, or prognosis of the patient's mental disorder.Axis IV - Diagnosis 1NAMENUMBERTYPEAxis IV - Diagnosis 2NAMENUMBERTYPEAxis V - Global Assessment of Functioning (GAF Score)Assessed level of functioning is intended to help the doctor draw up a treatment plan and evaluate treatment progress.Axis V - Diagnosis 1NAMENUMBERTYPEAxis V - Diagnosis 2NAMENUMBERTYPEIDD LEVEL (Please provide a response for each level and select N/A if it does not apply)*MILDMODERATESEVEREPROFOUNDN/A (Not Applicable)At RiskAutismBlindnessCerebral PalsyDeafnessDevelopmental DelayEmotionalHearing ImpairedLearning DisabilityOrthopedic ImpairmentVisual ImpairmentSpeech ImpairmentSeizureOtherIQ* Other DiagnosisPlease list any other diagnosis not previously mentioned above.Describe Physical ImpairmentDescribe Physical Impairment (Vision, Speech, Hearing, etc.)Describe Applicant's Ability to:Walk, Stand, Bend, Sit up, Use Arms, Legs, and HandsDate of Last Psychological Evaluation MM slash DD slash YYYY Measured Full Scale IQ Examiner's Name Current Residential Status*Select One...Group Home:ParentsFamily Home CareIndependentSupported LivingOtherPlease Specify Group Home Please Specify Family Health Care Home Please Specify Other Current Day Placement Status(Please select one...)SchoolWorkshopSupported EmploymentCommunity JobAdult Day HealthVolunteerOtherPlease Specify Other Assistance NeededSkill:What Type of Assistance Is Needed? Socialization and CommunicationSocialization* Initiates interaction with people Initiates interaction selectively with familiar people Interacts with peers, staff, and family Interacts with staff, but not with peers, and family Never or rarely interacts with staff, peers, and family Expressive Communication* Uses expressive language clearly Uses expressive language with difficulty Uses expressive communication acts Uses augmentative communication Uses vocalizations selectively Does not intentionally express self Uses ASL Uses sign Receptive Communication* Comprehends most spoken language Comprehends little spoken language Responds to gestures or auditory cues Attends to gestures or auditory cues Does not respond to communication Additional Comments Regarding Socialization and CommunicationMental Capabilities*Has the applicant ever been treated by a psychiatrist/psychologist, state hospital, or mental health center? Yes No Please Explain and Include Dates of TreatmentBehavioral HabitsDescribe any unusual or peculiar behavioral habits that UMAR should be made aware including sexual and psychological concerns.Relational Ability with OthersDescribe the applicant's ability to get along with others.Physically or Verbally Aggressive?*Is the applicant physically or verbally aggressive? Yes No Please ExplainInclude date of last aggressive episode.Cognitive AbilityDescribe the applicant's ability to remember, understand speech, and ability to think and respond.Is the Applicant Aware of Time and Space* Yes No Physical Health CareDoes applicant have seizures?* Yes (If yes, Specify Type and Frequency) No Please specify type of seizures below*Select One...Absence Seizures (aka petit mal)Tonic-Clonic (aka grand mal)Atonic Seizures (aka drop attacks)Clonic SeizuresTonic SeizuresMyoclonic SeizuresPlease specify frequency of seizures below*Select One...DailyWeeklyMonthlyYearlyNot within the last two yearsPlease List Any Known AllergiesClick the "+" sign to the right to add additional rows. Current Health StatusDoes applicant take medications outside of the home or during the day?*Select One...YesNoBehavioral ConcernsDoes the applicant display any of the behavioral concerns listed below? If yes, please rate severity accordingly. (Please provide a response for each level and select N/A if it does not apply)*1 = Mild2 = Moderate3 = SevereN/A (Not Applicable)AssaultiveCries/Screams ExcessivelyDamages PropertyEat InediblesInappropriate Sexual BehaviorLiesLoses Temper EasilyLow Tolerance to Being Physically HandledLow Tolerance to MusicLow Tolerance to Taking DirectionsNoncomplianceSelf InjuriousSelf StimulationStealsRuns Away PurposelyVerbal ThreatsWanders Away AimlesslyExplain All Above Rated BehaviorsDoes the Applicant Display Any Form of Physical Aggression?* Yes (If yes, please explain) No Please ExplainSocial HistoryEducationNameLocationDate List Any Special Education or Training Including Art Education/TrainingFor Day Program or Supported EmploymentList type of work and/or art experience.List the Applicant's StrengthsList Cultural or Religious PreferencesDescribe the Applicant's ChallengesApplicant StatementConsent - Rules and Regulations* I agree to the rules and regulations I hereby apply for admission to the UMAR Services program. I agree to abide by the rules and regulations of the program and understand that violation of the rules can result in immediate suspension and/or discharge.Consent - Drug Screening* Drug Screening If accepted, I agree that a drug screening may be required before entering a program at UMAR.Consent - Criminal Background Check* Criminal Background Screening If accepted, I agree that a criminal background screening may be requested before entering a program at UMAR.Consent - Acceptance of Use of Digital Signature* Agree to Use of Digital SignatureBy selecting this box, I accept the use of my personally typed name as my digital signature for this form.Applicant's Digital Signature* PLEASE NOTEBefore an application is accepted the following must be submitted to UMAR: - Most recent psychological report - Applicant's photograph - Case manager's name and agency with contact information - Current person centered plan (if applicable) - Signed paperwork in addition to the application Δ