Please Complete the

CCC Hangout Application Form

Parent's name

Address

City

Caregiver's Phone Number

Participant's Name

Participant's Date of Birth (so we can celebrate too!)

Participant's Sex

Participant's Diagnosis

What is the participant's interests and strengths?

How would the participant handle not wanting to participate in an activity?

In which areas does the participant require support?

Are there any behavioural issues?

Are there any medications that would need to be given during the program running from 1:30 pm to 4:30 pm? If so, how will they be administered?

What is the best time to contact you?

Please complete intake here: https://courageculture.mykajabi.com/offers/qkAyFg8R/checkout

Form submission[]