If you have any questions or comments about the instructions, feel free to email us.                

info@maplegrovetreatmentcenter.com

Participant Information

First Name      Middle Initial      Last Name

Date of Birth (00/00/0000)       Age          Sex      male  female

Parent or Gaurdian Name   

(All phone numbers should be given in the following format: 000-000-0000)

Home Phone      Cell Phone      Work Phone

Street Address

City      State     Zip Code

Participant's Email (if applicable) 

Parent or Guardian Email


Emergency Contact information

Primary Caregiver different then one listed above

Name

Cell Phone

Work phone

Person in case caregivers cannot be reached in an emergency

Name

Relationship to Participant

Home Phone

Cell Phone

Work Phone


Billing information

Select Payment Method(s)

Self-Pay
Insurance
County Waiver
County Family Support
ESY (for those who already qualify through their school district)

County Coordinator Name (if applicable)

County Coordinator's Email Address

County Coordinator's Phone 

If you are not funded through private insurance, skip the next section and go to Participation Information below.
________________________________________________________________________________

This Section is for Private Insurance funded participants only


Insured's Employer

Business Address

Insured's Business Phone

Insured's Birth Date

Name of Primary Insurance Company

Claims Address

Claims Phone Number

Subscriber Number

Group Number
_________________________________________________________________________________


Participation Information

Choose one
The Autism Summer Program
The Asperger's Summer Program
The Young Adult Asperger's Summer Program

Choose One
First 4 weeks: June 27- July 22
Second 4 weeks: July 25- Aug 19
8 weeks: June 27- Aug 19

Choose One
3 days per week
5 days per week

Please list any dates that you will be absent  from The Summer Program, or any special arrangements that were discussed.




Before and After Childcare (select one)
Yes
No
Not sure yet

Dates and times needed for childcare




Transportation (select one) (There is an additional fee for busing)
Self Transporting
Racine Bus
Germantown Bus


List any special considerations that we should attend to with the participant: including diet restrictions, medical needs, and/or custody issues (all information will remain confidential). 




If all of the information above is correct, click the submit button.