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His Path Developmental Day Program

Schedule

Monday, Tuesday, and Thursday from 8:30 AM – 4:30 PM.

For Additional Information

Contact Jenna Moore, His Path Program Director at:
or at 336-520-0260

Complete Application Below

Upon completion, you will immediately receive a successful completion prompt.

What are you registering for?
- HP Rockingham
- HP Winston Salem
Participants Info
Participant’s Full Name*
Nickname
Gender*
Height*
Weight*
Birthdate*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Guardian Info
Name of Parent/Guardian*
First Last
Parent/Guardian Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone - Cell*
Phone - Other
Emergency Contact Name*
First Last
Phone*
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.
TIME OF NEEDED SERVICE*
Please choose all that apply:
Respite is pre-determined based on client need. Other schedule variations may be available upon special request.
- Base Program: Monday-Friday; 9:00 am -- 3:00 pm
- Early respite: 7:00 am --9:00 am (additional cost of $10.00 per hour)
- Late respite: 3:00 pm --6:00 pm (additional cost of $10.00 per hour)
Note: Respite is pre-determined based on client need. Other schedule variations may be available upon special request.
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 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
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 Copy*
INSURANCE INFORMATION
Provider*
Primary Subscriber:*
Policy Number*
Group Number*
Effective Date
Date Format: MM slash DD slash YYYY
I give my permission for any medical treatment necessary for the participant’s health and well‐being.
Authorized Signature
Date*
Date Format: MM slash DD slash YYYY
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
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
CONTACT INFORMATION
For further information or questions contact:
Jenna Moore, His Path Program Director

For questions please contact:

Jenna Moore, Program Director at

MOUNT JUBILEE MINISTRIES

PO Box 81
Reidsville, NC 27323

Mount Jubilee Ministries, Inc. is a 501(c)(3) tax-exempt, non-profit organization.

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