Residential Membership

Employment

Recreation

Application Protocol

Resident Application

Initial Application for Residency

Applicant Information
Name
Street Address
City
State		Pick your state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Phone
Date of Birth		Month... January February March April May June July August September October November December Day... 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year... 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Gender		Male     Female
Diagnosis
Preferred Location		Minnesota     Montana

Communication (check all that apply)
		Is verbally fluent
		Uses short phrases
		Uses PECS
		Uses Sign Language
		Uses Augmentative Communication Devices
Independent Living Skills

		Independent		Requires minimal staff assistance		Dependent on assistance
Personal cares* (use detail below if needed)
Cooking
Cleaning
Shopping
Transportation
Finances
Personal Cares Detail
Dressing
Bathing/Shower
Toileting
Menstrual Care (women)
Shaving

Health/Medications (check all that apply)
		Understands and willingly reports changes in health condition
		Communicates pain/injury
		Requires third party observation of daily health condition
		Independently administers medication
		Requires medication management
Please describe current health conditions other than autism spectrum disorder:
Behavioral Issues History (check all that apply)
		Physical aggression
		Self-injurious behaviors
		Property abuse
		Verbal aggression
		Elopement/Leaving area
		Sexual abuse
Mobility (check all that apply)
		Navigates independently on community streets
		Navigates independently within known public buildings
		Navigates independently within home
		Needs close supervision at all times during waking hours
Do you have a drivers license? Yes   No

Personal Safety Briefly describe the level of supervision typically needed to maintain personal safety throughout the day and night ( e.g. capable of managing personal safety with minimal oversight such as check-in morning and night, check in at employment/all activities, needs 24 hour supervision.) Describe:
Education (indicate your highest level of education completed)
		High School Graduate Degree
		Technical College Degree
		Some College
		Undergraduate Degree
		Some Graduate School
		Graduate Degree
Would you be interested in pursuing a college education while living at Erik’s Ranch? (if developmentally appropriate) Yes   No In what area(s) of study are you interested?

Social activities of interest:
General areas of interest:
Volunteering experience:
Employment Experience
Have you previously been employed? Yes   No If yes, please briefly describe the position(s) and how long was your employment with the company:
Additional information you would like to share:
Responsible Party Information
Name
Street Address
City
State		Pick state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Phone
Best time to be reached
Email
Relationship to applicant
Other information you would like to share:
Required fields in bold.