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MOVING FORWARD DAY PROGRAM

Background Information &

Registration

ACADEMIC YEAR - SHORT FORM

CLIENT INFORMATION

First Name *

Last Name *

Date of Birth * +

Street Address *

City *

Province *

Postal Code *

Home Phone Number *

OHIP No: *

PRIOR ENROLMENT IN MOVING FORWARD DAY PRGORAM

Was the above-named adult enrolled in Moving Forward Day Program during the previous most recent academic year? *

Yes

No

If YES, please review the different sections of the online registration form shown below and indicate which you wish to update.

If NO, you must complete the full registrattion form. This form can be found by clicking on this link:

MF Full Registration Form

Please note: Moving Forward Day Program assumes no responsibility or liability arising from inaccurate or out-of-date inforamtion provided in this online registration form.

PHYSICIAN INFORMATION *

Needs to be updated.

You may use the info I provided in the last academic year

PARENT INFORMATION & EMERGENCY CONTACT *

Needs to be updated.

You may use the info I provided in the last academic year

MEDICAL BACKGROUND *

Needs to be updated.

You may use the info I provided in the last academic year

NEEDS ASSESSMENT *

Needs to be updated.

You may use the info I provided in the last academic year

BEHAVIOURAL BACKGROUND *

Needs to be updated.

You may use the info I provided in the last academic year

PHYSICAN INFORMATION

Name of Primary Physician *

Medical Facility Name: *

Street Address *

City *

Phone Number *

PARENT INFORMATION & EMERGENCY CONTACT

Parent First Name *

Parent Last Name *

Relationship *

Home Phone Number *

Mobile Number *

Same address as above *

Yes

No

Street Address *

City *

Province *

Postal Code *

Home Phone Number *

Mobile Number *

In case of emergency, contact parent indicated above *

Yes

No

If "no", please provide alternate emergeney contact:

First Name *

Last Name *

Relationship *

Home Phone Number *

Mobile Number *

MEDICAL BACKGROUND

Diagnosis Information - please check all applicable boxes: *

Autism	Vision Impaired	Hearing Impaired
Brain or Neurological	Cerebral Palsy	Epilepsy
Down Syndrome	Physical Disability	Mood Disorder
Depression	Developmental Delay	Other Other

Provide addition details on diagnosis, as required:

Allergies: *

Yes

No

If "yes", please provide additional details: *

Currently taking medication: *

Yes

No

Med #1 *

Frequency *

Dosage *

Med #2

Frequency

Dosage

Will medication need to be administered by the Moving Forward Day Program *

Yes

No

If "yes", please provide details below: *

NEEDS ASSESSMENT

Mobility *

Walks without aids	Walks with aids, i.e., cane, crutches
Requires one-to-one assistance	Does not walk
Usually in a wheelchair	Other Other

Literary *

Able to read	Unable to read	Able to write
Unable to write	Can recognize numbers	Other Other

Independence *

Requires minimal supervision	Requires constant supervision
Other Other

Self Care *

Able to wash hands	Able to toilet independently
Able to feed independently	Able to dress independently
Able to put on boots, shoes & outer jacket	Other Other

Please provide any additional information that you believe is relevant:

BEHAVIOURAL

Please provide details of any behavioural issues:

REGISTRATION & GENERAL INFORMATION

Academic Year: September 2019 to June 2020

The academic year runs from the Tuesday of the first week of September to the last Friday of June the following year. Please note, all rates indicated include $16.50 for the YMCA pass.

Please select the desired program:

Two days/week: $764.50	Three days/week: $1,138.50
Four days/week: $1,512.50	Five days/week: $1,776.50

If you selected less than five days per week, indicate below the days of attendance:

Monday

Tuesday

Wednesday

Thursday

Friday

_____________________________________________________________________________________

General Information

Payment: Payment is by post-dated cheque, due at the commencement of the program.

Withdrawal Notification: Fifteen days (15) written notification is required to withdraw from the program or make changes to the selected program days.

Extended Hours: The Moving Forward Day Program operates from 9 am to 4 pm. If you require support beyond these hours, notification must be provided at least 24 hours notice in advance to make staffing arrangements. A nominal fee may apply.

YMCA Memebrship: We have secured reasonable rates for membership in Oakville and Mississauga. We will be using the YMCA facilites as part of our recreational program. The pass remains at the day program and used between the hours of 9:00 am to 4:00 pm. The $16.50 monthly YMCA fee is included in all rates quoted above.

Outings: Every month, clients will have the opportunity to attend an outing or two that may require an extra fee. Some of the outings in the past include: lunch at a local restaurant, bowling, movies, mini putt and a boat trip. Staff will help clients agree on a location and parents will be informed in the agenda of the cost. These activities are optional.

SIGN OFF

Name: *

Signature (Please type full name): *

Date +

BILLING

Billing

Your sales receipt will be sent by email in PDF format during the first week of the current month.

Email address: *

Please indicate if you require the monthly invoice to be split, i.e., paid by two different parties: *

Yes

No

Name of Person #1

Email Address

Amount to invoice *

Name of Person #2

Email Address

Amount to invoice *

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