His Path Application

What location are you registering for?*

HP Rockingham County (3 days - Monday, Tuesday, Thursday)
HP Forsyth County (4 days - Monday, Tuesday, Wednesday, Thursday)
HP Guilford County (3 days -Tuesday, Wednesday, Thursday)

How many days per week are you interested in the participant attending?*

Are there particular days you are interested in the participant attending?

Monday (Reidsville & Winston)
Tuesday (all locations)
Wednesday (Greensboro & Winston)
Thursday (all locations)

Participants Info

Participant’s Full Name*

Nickname

Gender*

Height*

Weight*

Birthdate*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Info

Who is filling out this application?*

Participant - adult with I/DD
Parent - Father
Parent - Mother
Guardian

Name of Parent/Guardian filling out the application*

First Last

Employment - parent/guardian*

Employer Position

Parent/Guardian Email*

Parent/Guardian Phone - Cell*

Name of second parent/guardians (if none, enter N/A in appropriate fields)*

First Last

Employment - Second parent/guardian*

Employer Position

Email - Second parent/guardian*

Phone - Cell - Second parent/guardian*

Parent/Guardian Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone - Other

Emergency Contact Name other than parents/guardian*

First Last

Phone*

Family Church Affiliation - if none, put N/A*

General Information

DEGREE OF DISABILITY*

Please choose one of the following:

Mild: able to perform all activities of daily living in self‐care and movement at normal speed.
Moderate: performs all activities, but not at normal speed.
Severe: unable to perform all activities of daily living.

LOCATION OF SERVICE*

Please choose that which applies to you.

Rockingham Program: Monday, Tuesday, & Thursday; 8:30 am -- 4:30 pm
Forsyth Program: Monday, Wednesday, & Friday; 8:30 am -- 4:30 pm
Guildford County: Tuesday, Wednesday, & Thursday; 8:30 am -- 4:30 pm

Note: There are times when parents/guardians would like to request additional attendance days Schedule variations may be available upon special request to the program coordinators and after approval by the program director. These days will be at an additional fee of $10/hour.

Can the participant speak and be understood?*

Please select the most appropriate answer:

Yes
No

Can the participant hear?*

Please select the most appropriate answer:

Yes
No

Is the participant able to walk?*

Please select the most appropriate answer:

Yes
No

Does the participant use a walker and/or wheelchair?*

Please select the most appropriate answer:

Yes
No

Does the participant like to be touched?*

Please select the most appropriate answer:

Yes
No

Does the participant exhibit distracting or disruptive behavior?*

Please select the most appropriate answer:

Yes
No

Does the participant exhibit self-injurious or aggressive behavior?*

Please select the most appropriate answer:

Yes
No

For the preceding two questions describe the behavior and what triggers it.

Explain how does the participant react to crowds or loud noise?*

Is the participant able to feed him/herself?*

Please select the most appropriate answer:

Yes
No

Does the participant have difficulty swallowing?*

Please select the most appropriate answer:

Yes
No

Should food be soft or softened for easy of eating?*

Please select the most appropriate answer:

Yes
No

Does the participant have a tendency to overeat?*

Please select the most appropriate answer:

Yes
No

If so, how do you handle this?

List any special dietary instructions:

List any foods that should not be given to the participant:

Is the participant able to control bowels and bladder?*

Please select the most appropriate answer:

Yes
No

Is the participant able to express his/her need to use the toilet?*

Please select the most appropriate answer:

Yes
No

Can the participant use the toilet independently?*

Please select the most appropriate answer:

Yes
No

How often should the participant be taken to the toilet?

Does the participant have a 1-1 support staff that would attend with them?*

Yes
No

While His Path is currently unable to supply 1-1 support staff for our participants, we gladly welcome any such staff employed by the family.

Does the participant need any adaptive equipment?*

Please select the most appropriate answer:

Yes
No

If so, please explain the nature of the equipment:

List any special precautions we should take in the care of this participant.

Field trips may include swimming and participants will be required to take a swimming test to determine their swimming abilities.

Describe participant’s swimming competency:

Describe any activities or things the participants enjoys doing?

Describe any activities or things the participants dislikes doing?

Please give any other information that would be of help in caring for this participant.

MEDICAL INFORMATION

Primary Care Physician Name*

Primary Care Physician Address*

Primary Care Physician Phone Number*

Diagnosis or description of handicap/disabilities:

List any known allergies (drugs, foods, insects, latex, etc.):

If participant has an allergy, do they have an epinephrine pen?*

Please select the most appropriate answer:

Yes
No

Does the participant have any known communicable diseases?*

Please select the most appropriate answer:

Yes
No

If yes, please list (HIV/AIDS, Hepatitis, etc.):

List all current medications including name, times given, dosage and any special instructions:

If this information is not included, in case of emergency, general safety protocol will be followed.

Special note: If any medication is to be given while the participant is at His Path, be sure that it is sent in the original prescription containers, with the participant’s name and instructions on the bottle. Be sure that the dosage on this application and on the bottles are the same. Parental permission for medicine distribution is required.
***A copy of current (within one year) physical will be required to be submitted with registration.

INSURANCE INFORMATION

Provider*

Primary Subscriber:*

Policy Number*

Group Number*

Effective Date

I give my permission for any medical treatment necessary for the participant’s health and well‐being.

Authorized Signature

Date*

NOTE: Please provide copy of all insurance/Medicaid/Medicare ID card(s)

PERMISSIONS

All participants are required to have permissions signed by a parent or guardian.

Permission to Photograph - Participant’s name:

Photos may also be used in promotional presentations of His Path Developmental Day Program. Be assured that the pictures will not be sold, solicited, defamed, or used in any way that would knowingly bring harm or shame to anyone.

Please mark one of the below:*

I give permission for my participant to be included in photos.
Do not include my participant in pictures to be used for promotion.
Do not include my participant in ANY pictures.

Authorized Signature

Permission to Travel - Participant’s name:

has my permission to travel with authorized personnel affiliated with Mount Jubilee Ministries, Inc. This permission includes travel to and from activities in the His Path Developmental Day Program schedule and any necessary transportation for the well‐being of the participant.

Authorized Signature

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APPLICATION INFORMATION

DEPOSIT: $100 refundable with registration, to be applied to the first week of service upon acceptance. INTERVIEW: Question and answer meeting with parent, applicant and His Path representatives.
COST: $175 per week (base price)
RESPITE: $10 an hour as needed
Payable to:

Mount Jubilee Ministries
PO Box 81
Reidsville, NC 27323

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CONTACT INFORMATION

For further information or questions contact:
Jenna Moore, His Path Program Director

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Participants Info

Parent/Guardian Info

General Information

MEDICAL INFORMATION

INSURANCE INFORMATION

PERMISSIONS

APPLICATION INFORMATION

CONTACT INFORMATION

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