Application Form
Name of individual with disability Social Security Number
o Male o Female
Date of Birth County of Residence Home Phone
Street or Box Address
City Zip Code
Responsible Adult Name Address Phone
2nd Responsible Adult Name if Applicable Address Phone
Total children in family Total adults in family No. Children with disabilities No. Adults with disabilities
Name of Person Who Referred You to Us Their Agency/Organization
Address of Referring Person Phone
Disabling Conditions (check all that apply):
o Mental Retardation o Seizure Disorder/Epilepsy o MR & MI Dual o Deaf Blind
o ADD/ADHD o Paraplegia o Developmental Delay o Autism
o Cerebral Palsy o Quadriplegia o Muscular Dystrophy o Cystic Fibrosis
o Neurologic Disorder o Traumatic Brain Injury o Multiple Sclerosis o Spina Bifida
o Orthopedic Disorder o Visual Imp./Blindness o Hearing Imp./Deafness
o Other
Please describe your need or needs at this time?
We ask for the following information just for our records and it has no effect on your receiving help from us:
Race: o Caucasian o Hispanic o Afro-american o Native American o Oriental o Other
Currently Getting Help From:
o Medicaid o Medicare o Private Insurance o SSI o Dept. of Mental Retardation
o Dept. of M. Health o Voc. Rehab. Serv. o AFDC/FAPRA o Children�s Rehab. Serv. o Head inj. Found.
o Community Action o A church o Epilepsy Found. o Catholic Soc. Services o Other
PERMISSION TO RELEASE INFORMATION
All the above information is true to the best of my knowledge, and I give my permission for the following individual or agency to release information about myself or my family member listed above for the purpose of determining eligibility for assistance from the Individual & Family Support Service. I know this information will be private and used only to determine if I or my family member is eligible for services. I also know that my permission is voluntary and at any time can be refused to any individual or agency listed below in the DISABILITY VERFICATION section (fill in Printed Name or Agency/ Organization below).
The information checked below may be exchanged to determine eligibility:
o Medical reports/records o Progress reports o Psychological test results
o Social/developmental history o Therapy testing reports o Speech/language testing reports
o Screening or intake information o Staffing reports o vision/hearing records
o Developmental testing records o Other
This release will be effective for 90 days 6 months 1 year.
Signature Please print name Date
DISABILITY VERIFICATION
Note:
Verification of the disability must come from someone other than the individual requesting assistance or a family member. Common sources of verification are doctors, social workers, special ed. school personnel, service providers such as Children�s Rehabilitation Service, UCP, Easter Seals, MARC, Vocational Rehabilitation Service, and Alabama Institute for Deaf and Blind.
A professional who can verify the Disability or Traumatic Brain Injury must sign below.
Description of Disability:
Verified by:
Signature Printed Name
Agency/ Organization
Address
Phone
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