RADD Group Home/Adult Family Application Form

Personal Infromation






Participant Name Gender Birth Date Diabetic? Income Ethnicity Wheelchair?
1. Female
Male
Yes
No
More than $10,980
Less than $10,980
WhiteAfrican American
AsianHispanic, Latino
American IndianOther
Yes
No
2. Female
Male
Yes
No
More than $10,980
Less than $10,980
WhiteAfrican American
AsianHispanic, Latino
American IndianOther
Yes
No
3. Female
Male
Yes
No
More than $10,980
Less than $10,980
WhiteAfrican American
AsianHispanic, Latino
American IndianOther
Yes
No
4. Female
Male
Yes
No
More than $10,980
Less than $10,980
WhiteAfrican American
AsianHispanic, Latino
American IndianOther
Yes
No

Will participants be coming with support staff?

Yes No

PLEASE NOTE: If participant will not be coming with support staff, an INDIVIDUAL APPLICATION needs to be filled out.

Do you have any clients who are new to RADD?

Yes No

The following questions are designed to help us measure the participants progress within our programs. It is an important tool for RADD and its Funders to evaluate how our programs are working.
Please rate the client using the following scale. Circle the correct number for each statement.

  1. Requires full assistance to complete/demonstrate the task.
  2. Requires prompting to complete/demonstrate the task.
  3. Completes/demonstrates the task without prompting.
  4. Independently completes/demonstrates the task in all settings and situations.
SkillsParticipant #1Participant #2Participant #3Participant #4
Gets own bowling ball 1234 1234 1234 1234
Gets bowling shoes from counter 1234 1234 1234 1234
Finds assigned bowling lane 1234 1234 1234 1234
Bowls when it is their turn 1234 1234 1234 1234
Checks in at sign-in table at events 1234 1234 1234 1234
Orders and pays for concessions 1234 1234 1234 1234
Gets materials needed to complete a given task 1234 1234 1234 1234
Participates in assigned activities 1234 1234 1234 1234
Is willing to try new things 1234 1234 1234 1234
Initiates peer interactions 1234 1234 1234 1234
Gives and receives compliments 1234 1234 1234 1234
Respects individual differences 1234 1234 1234 1234
Assumes responsibility for self 1234 1234 1234 1234

RADD LIABILITY WAIVER

As a consideration for being permitted to participate in activities sponsored by RADD, also known as the Cerebral Palsy Agency of Racine County, Inc., and/or using equipment, facilities or property of said establishment, such client or user agrees to assume all liability for injury and/or damage resulting from such participation or use and further agrees to hold the Cerebral Palsy Agency of Racine County, Inc. free and harmless on account of any act of omission, commission, or negligence on the part of the Cerebral Palsy Agency of Racine County Inc. or any of their officers, agents, employees or volunteers.

RADD may photograph said client together with any subject matter owned by the undersigned, and so hereby authorize the Cerebral Palsy Agency of Racine County Inc. to cause the same to be exhibited as still photographs, transparencies, motion pictures and/or television. The undersigned does hereby release the Cerebral Palsy Agency of Racine Inc. its employees and agents from any and all claims for damages, libel, slander, invasion of the right of privacy, or any other claim based on the use of said material.

In the event of an accident or sickness to said individual, the Director may obtain such medical, hospital or surgical assistance and service as he/she may deem necessary, and I/we here agree to pay such charges, indemnify RADD and hold same harmless for such charges. RADD may exchange information it possesses relative to said individual to any qualified agency or doctor, provided such information may be used for purposes of selection only.



I declare all the above information is correct and agree to the terms in the above waiver.
By checking this box, you consent that all of the above information is correct.