APPLY TO HERITAGE FARM

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Housing Situation *

Please check one.

Live on Own

Live with Family

Live with Residential Provider

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number 1 *

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Phone Number 2

(###)

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Phone 3

(###)

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Waiver Enrolled *

Yes

No

Guardian Status *

Check A, B, OR C.

A. I am UNDER 18 years old. (Minor)

B. I am 18 years OR OLDER, have NO Legal Guardian and am a Guardian of Self.

C. I am 18 years OR OLDER and HAVE a Court Certified Guardian through County Surrogate Court/other Court)

Provider Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Provider Phone Number *

(###)

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Fax Number

(###)

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Provider Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Provider Phone Number

(###)

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Fax Number

(###)

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Pharmacy Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pharmacy Phone Number *

(###)

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Fax Number *

(###)

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Vision-Needs corrective lens? *

Yes

No

Vision-Impaired (Blind or Low Vision)

Right Eye

Left Eye

Are there any behavioral issues that would interfere with services requested or require specific staff support? Check all that apply. *

No

Yes-verbal outbursts

Yes-physical outbursts

Yes-physically assaults others

Yes-elopes

Yes-sexually inappropriate

Yes-self-injurious

Yes-property destruction

Yes-PICA

Yes-steals

Yes-other (please explain)

Person Completing Application *

First Name

Last Name

Date *

MM

DD

YYYY

Phone Number *

(###)

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Fax Number *

(###)

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Self-Direction *

Yes

No

Phone Number

(###)

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Phone Number

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