The Arc Studio Collective

Applicant Full Name *

Date of Birth *

Street Address *

Apartment, suite, etc

City *

State *

ZIP *

Phone Number *

Has the court named someone as the legal guardian? *YesNo

Name *

Street Address *

Apartment, suite, etc

City *

State *

ZIP *

Phone Number *

Emergency Contact Person

Name *

Street Address *

Apartment, suite, etc

City *

State *

ZIP *

Phone (day) *

Phone (night) *

Relationship *

Family Summary

Describe the applicant's typical social activities, food and entertainment preferences, and interactions with others. *

The Arc Studio is a stimulating environment and can be loud and busy at time. Do you anticipate this kind of environment posing a challenge for the applicant? *YesNo

Please explain.

Medical History

Indicate if the applicant has any of the following illnesses and/or chronic conditions.

Epilepsy, CP, MS, Parkinson's Neuritis, Paralysis, Alzheimer's disease or any other disease of the Central Nervous System *YesNo

Heart attack, murmur or palpitation or high blood pressure, anemia, varicose veins, or any other disease of the heart, blood, or blood vessels *YesNo

Tuberculosis, asthma, pleurisy, or any other disease of the lungs, bronchial tubes, throat, or respiratory system *YesNo

Ulcer, indigestion, colitis, gall stone, hernia, or any other disease of the stomach, intestines, rectum, gall bladder, or liver *YesNo

Urinary sugar, albumin, or stone, sexually transmitted disease, menstrual disorder, or an other disease of the breasts, kidneys, urinary or genital systems. *YesNo

Diabetes, gout, or any other disease of the thyroid or other glands *YesNo

Arthritis, rheumatic fever, back trouble, or any other disease of the joints, muscles, or bones *YesNo

Clinical Depression, Schizophrenia, Bipolar Disorder, or any other mental illness *YesNo

Intellectual Disability, Autism, or any other developmental disability *YesNo

Current significant medical problems, communicable diseases, or recent physical complaints of the applicant, if any:

List applicant's drug or food allergies, if any.

History of seizures? *YesNoUnknown

Are the seizures under control? *YesNoPartiallyUnknown

Are seizures controlled *with medication?without medication?

Support Needs

Please explain *

How frequently does the applicant require support or assistance in walking or standing? *RarelySometimesOftenAlways

Does the applicant use a: *walkerwheelchairother equipment

Please explain: *

How frequently does the applicant require support or assistance in making their needs known or getting along with others? *RarelySometimesOftenAlways

What is the applicant's primary means of communication? *Verbal SpeechSign LanguageGesture, Communication BoardVocalization (no speech)

How frequently does the applicant require support or assistance with eating, dressing, using the bathroom, personal hygiene, or is at a risk of falling? *RarelySometimesOftenAlways

Is the applicant an elopement risk? *YesNo

Describe the applicant's intellectual functioning. *Mild Intellectual DisabilityModerate Intellectual DisabilitySevere Intellectual DisabilityProfound Intellectual DisabilityUnknownDoes not have Intellectual Disability

Please describe any behavioral supports that have prove to be successful for the applicant: *

Additional Comments:

Please read and check the following boxes. *I understand that although The Arc Studio is staffed and that every effort will be made to ensure the safety of those involved, and accident may occur.I will not hold The Arc of the Piedmont, including The Arc Studio, nor any of its members responsible for any injury, physical or otherwise, incurred by any of the participants during The Arc Studio activities.I give my permission to the staff of The Arc Studio to seek medical help for the applicant, if needed.I understand that there is a fee of $10 per hour-long session due monthly to be a member of The Arc Studio Collective. (Ex. If a TASC artist plans to attend twice a week for four weeks, the monthly fee will be $80.)

Signature *

The Arc Studio Collective

Emergency Contact Person

Family Summary

Medical History

Indicate if the applicant has any of the following illnesses and/or chronic conditions.

Support Needs

1149 Rose Hill Drive Charlottesville, VA 22903 (434) 977-4002

1149 Rose Hill Drive
Charlottesville, VA 22903
(434) 977-4002