The application form for the Artful Impact creative learning program is designed to determine whether a potential client is a suitable candidate for the program. It gathers essential information about each applicant’s strengths, interests, and support needs, ensuring that we can provide an environment where they can thrive.

The form includes sections on educational background, vocational experience, and daily living skills. Questions also focus on communication abilities, mobility, and social skills to help us understand the applicant’s current level of independence and any areas that might need additional support. Additionally, applicants or their families can share information about personal interests, goals, and previous experiences in work or volunteer settings, helping us assess how well they align with the program’s hands-on, skill-building approach.

This form will serve as an initial step in evaluating whether our program’s structure, resources, and support levels are the best fit for the client’s unique needs and aspirations. This careful selection process helps us ensure that each participant will benefit from the training and contribute meaningfully to our community. Once your application has been submitted, you will receive a confirmation email that it was received. Your application will then be reviewed and we will get back to you within 10 business days. Should you have any additional questions during that time, please don’t hesitate to email artfulimpactstudio@gmail.com.

PERSONAL INFORMATION

The privacy and security of our applicants’ personal information are of utmost importance. This policy outlines how we handle the personal information collected through the application process for our vocational training program.

A. Purpose of Collection

All personal information provided on the application form will be used exclusively to determine the applicant’s eligibility and suitability for the Artful Impact program. This information helps us assess the individual’s needs, strengths, and potential for success in the program.

B. Confidentiality

We are committed to safeguarding the confidentiality of all personal information shared with us. Only authorized staff involved in the application and admissions process will have access to this information.

C. Data Security

Personal information will be stored in a secure environment, and measures will be in place to protect against unauthorized access, loss, or misuse. Any physical copies will be stored in locked, restricted-access areas.

D. Retention and Disposal

Personal information of applicants who are not accepted into the program will be securely destroyed within a month of determination. For accepted clients, personal information will be retained only for the duration of their involvement in the program and any required follow-up period thereafter, after which it will be securely disposed of.

E. Contact Information

First name

Last name

Birthday

Month

Day

Year

Gender

Single choice

Female

Male

Prefer not to say

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Phone

Emergency Contact (Name, Relationship, Contact Information):

2. DISABILITY INFORMATION

You may be asked to provide a copy of relevant documents including a current IEP or learning plan.

A. Do you have a disability?

Yes

Disability Diagnosis (If available)

B. Do you require any specific accommodations for your disability?

Yes

If you answered yes, please specify. (i.e. - Wheelchair access, assistive technology, etc.)

Please describe if any of the above were checked.

3. HEALTH CONCERNS

If you answered ‘other’ above, please describe your health condition.

B. Please provide any additional information regarding any health conditions selected above

C. Do you have any specific allergies?

Medication Allergies

Food Allergies

Other

None

Please describe your specific allergies.

D. Are you currently taking any medications?

Yes

E. Would you need to take any medications during the time you are at the program?

Yes

Maybe

F. Do you require any special dietary needs? (i.e. Gluten Free, Lactose Intolerant, Specialized Diet, etc.)

Yes

Maybe

If you answered Yes or Other above, please specify

G. Can you independently complete the following: (check the ones that apply)

4. BEHAVIOR CONCERNS

You may be asked to provide a copy of a recent behavior intervention plan if applicable.

A. Do you have any behavioral concerns that might affect your participation in the program?

Yes

Maybe

Please describe any potential behavior concerns

B. Have you ever been involved in any of the following behavioral interventions? (select all that apply)

C. Are you currently involved in any of the following behavioral interventions? (check all that apply)

Please describe the interventions currently being used, how long they have been in place and their effectiveness.

5. EDUCATION I WORK HISTORY

B. Check the box(es) that best describe your high school education level

C. Are you currently employed?

Yes: paid, part-time employment

No, but volunteering

Yes: paid, full-time employment

If you are currently employed, please give your employer name and description of your job.

D. Previous Work Experience - Please list all (include employer, job title and/or job duties)

If you have a transition portfolio that you would prefer to share, that is also an option.

E. Do you have any other vocational experience, certifications or training?

Yes

Maybe

If yes, please describe.

F. Are you able to independently work without supervision?

Yes

Maybe

G. How often do you require assistance when completing tasks?

Rarely

Sometimes

Often

Always

H. Are you able to complete tasks within a given time?

Yes

Maybe

I. What are your work preferences?

Work alone

Work in a team

I like both

SOCIAL SKILLS

B. Do you find it difficult to communicate with others?

Yes

Maybe

C. Do you work well in a small group

Yes

Maybe

D. Are you comfortable asking for help when needed?

Yes

Maybe

STRENGTHS, HOBBIES AND INTERESTS

B. Describe your favorite interests or hobbies.

8. QUESTIONS ABOUT YOU

A. What goals do you have for yourself when it comes to work? Why do you want to attend Artful Impact?

B. Is there anything else you would like us to know?

9. REFERENCES

Please provide the contact information for two individuals who can speak to your skills, work habits, and suitability for the program. These references may include former or current teachers, job coaches, supervisors, or other individuals familiar with your abilities and character.

Reference #1 (Include name, phone number or email, and the relationship to applicant (e.g., former teacher, job coach, former/current boss)

Reference #2 (Include name, phone number or email, and the relationship to applicant (e.g., former teacher, job coach, former/current boss)

10. CONSENT AND AGREEMENT

I consent to the processing of this application for the purpose of determining eligibility to attend the Artful Impact, LLC program. (Submitting an application does not guarantee acceptance to the program.)

Single choice

Yes

By typing/signing my name, I certify that all the information provided in this application is accurate and complete to the best of my knowledge.

Applicant

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year

Guardian

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year

PERSONAL INFORMATION

Gender

2. DISABILITY INFORMATION

3. HEALTH CONCERNS

4. BEHAVIOR CONCERNS

5. EDUCATION I WORK HISTORY

SOCIAL SKILLS

STRENGTHS, HOBBIES AND INTERESTS

8. QUESTIONS ABOUT YOU

9. REFERENCES

10. CONSENT AND AGREEMENT

Application

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