Wings Application Step 1 of 4 - General Information 25% New Member ProcessTo be a member in Wings Program, applicant must be able to walk on their own, feed themselves, get along with others and feed themselves. The Application Process, in order is: Complete Member Application, Program Tour, Interview with Staff, 30-Day Trial Period, Full Acceptance into Day ProgramApplicant’s Name* First Last Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Relationship to Applicant*Email* Cell Phone*Additional Parent/Guardian Name [if applicable] First Last Relationship to ApplicantEmail Cell Phone Please Select Program Option For Which You Are Applying* Full-Time [9:00a - 4:00p Mon - Thu & 9:00a - 1:00p Fri] :: $770/month Part-Time AM [9:00a - 1:00p Mon - Fri] :: $529/month Part-Time PM [12:00p - 4:00p Mon - Thu] :: $482/month How did you hear about Wings?*Check all that apply Member Friend Family Social Media Email I attended an event hosted at Wings (Wedding, Pumpkin Patch, etc) Other Friends name who told you about Wings:Family members name who told you about Wings:If "Other" please explainWhy does the applicant wish to participate in this program(s)?* What is the applicant’s future educational/vocational/training goals?Please describe the applicant’s disability and indicate the challenges facing the applicant as a result of the disability.*Please describe any behaviors that we should be aware of and the most effective response to these behaviors:*Applicants verbalization*Predominantly non-verbalSomewhat verbalPredominantly verbalHow does the applicant best communicate?*Check all that apply Verbally Sign Language Speaking device Gestures Sounds Written Does the applicant get along well with others? Please explain any concerns.What is the applicant’s reading ability?*Please describe applicant’s personality:*What types of assistance does the applicant need on a daily basis?*Please describe applicant’s daily routine and leisure activities:*Is the applicant currently employed?*YesNoIf Yes, please describeList three specific goals/expectations you have for the applicant?1.2.3.Are you seeking [or will you be interested in] private residential care in:* 5 years 10 years Not Interested I am signing as applicants*PARENTGUARDIANParent/Guardian Signature*I affirm that the preceding information is a complete and true statement of all the facts and circumstances relative to this member’s application for enrollment in any WINGS program. I also understand that submission of this form in no way guarantees placement in any WINGS program, but is merely intended to express interest in the possibility of future participation. Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date* Date Format: DD slash MM slash YYYY