Membership Application

Application for Becoming a SHINE member

Thank you for your interest in SHINE - Joplin. Please complete and return the following application. The Admissions Committee conducts a thorough study of the information provided, determines the placement availability and suitability of each applicant, and notifies you whether or not to continue with the next step in the application process.

All applicants to SHINE must be age 21 or older.

SHINE is an approved day habilitation provider through the Developmental Disability Resource Board of Jasper County. Check with your case manager to see if you qualify for financial assistance.

REQUESTED PLACEMENT DATE:^*

APPLICANT INFORMATION

Applicant Name:^*

Applicant Birthdate:^*

Applicant Preferred Name:^*

Applicant Phone:^*

Applicant SSN:^*

Applicant Current Address:^*

Applicant's City^*

Applicant's State:^*

Applicant's Zip:^*

Applicant's Height:^*

Applicant's Weight:^*

Applicant's Genbder:^*

MaleFemale

Legal Guardian Name of Applicant:^*

Relationship with Guardian:^*

Guardian Home Address:^*

Guardian's City:^*

Guardian's State:^*

Guardian's Zip:^*

Guardian's Preferred Email:^*

Guardian's Occupation/Company Name:^*

Guardian's Home Phone:^*

Guardian's Cell:

Guardian's Work:

PLEASE CHECK WHICH OF THE FOLLOWING APPLIES TO THE APPLICANT:

likes people

gets along well with friends

follows directions willingly

shows concern

tends to be a loner

respects rights & property of others

gets angry easily

tends to be shy initially

sensitive to light

sensitive to touch

sensitive to sound

can get easily agitated/irritable

gets anxious

has self-stemming behaviors

perseverates

can introduce self

forms close relationships

is generally happy

other

WHICH OF THE FOLLOWING APPLY TO THE APPLICANT’S SPEECH/LANGUAGE AND COMMUNICATION SKILLS?

speaks spontaneously

can make wants and needs known

uses complete sentences

has small vocabulary

uses sign language

understands lengthy dialogue

makes little or no effort to communicate verbally or with gestures

understands short, direct commands

communicates by writing

comprehends written statements

uses gestures effectively

uses sentences effectively

uses idiosyncratic gestures

uses a communication device- please describe:

Describe the applicant’s speech and language effectiveness:

SELF-HELP SKILLS

Will an attendant accompany the applicant?^*

YesNo

If so, what is their primary role?^*

MEALS

no assistance needed

total assistance needed

some assistance needed

needs a straw for liquid

food needs to be cut/chopped

able to prepare meals

able to use microwave independently

Special instructions- Meals

MOBILITY

walker

braces

crutches

manual wheelchair

electric wheelchair

not able to stand for prolonged periods of time

unsteady gate

has physical limitations that limit participation in activities

Special instructions - Mobility

TOILETING

no assistance needed

help transferring

help cleaning up

wets bed

diapers/depends

assistance needed only after a bowel movement

Bowel Control

Bowel full control

limited control

no control

Bladder Control

full control

limited control

no control

Special instructions:

Additional comments:

FINANCIAL INFORMATION

Listed below are the fees associated with the Day Programs. SHINE strives to provide financial assistance to those in need and to those who qualify.

Day Program
$100/month – 1 day per week
$200/month – 2 days per week

Will you be requesting financial assistance?^*

YesNo

REFERENCES

Reference 1 Name:

Reference 1 Phone:

Reference 1 Email:

Reference 1 Address:

Reference 1 City:

Reference 1 State:

Reference 1 Zip:

Reference 2 Name:

Reference 2 Phone:

Reference 2 Email:

Reference 2 Address:

Reference 2 City:

Reference 2 State:

Reference 2 Zip:

Reference 3 Name:

Reference 3 Phone:

Reference 3 Email:

Reference 3 Address:

Reference 3 City:

Reference 3 State:

Reference 3 Zip:

Please list three (3) individuals (different from those listed on page 3) who have worked with or known the applicant closely:

APPLICATION SIGNATURES

I affirm that the preceding information is a complete and true statement of all the facts and circumstances relative to this participant’s application for enrollment at SHINE - Joplin’s residential or day program to the best of my knowledge. We, the undersigned, do give our permission for SHINE - Joplin to contact any and all of the references, programs, schools, and professionals listed on this application.

I also authorize anyone who has any information on this client to release said information they hold on him/her to SHINE - Joplin.

Copies of this release may be used to obtain information from anyone listed on application for acceptance into SHINE - Joplin.

I understand and acknowledge that this application is not a guarantee of becoming a member of SHINE – Joplin. The applicant will be added to a pool of other applicants for the directors to assess who may best fit the program.

Signature of Parent/Guardian:^*

Signature Date:^*

Signature of Applicant (if appropriate):

Date:

If application was filled out by someone other than parent/guardian, please sign below:

Signature of Applicant (if appropriate) - If filled out by someone else

Relationship With ( If filled out by someone else )

Date ( If filled out by someone else )

PHOTOGRAPH/IMAGE CONSENT

SHINE - Joplin would like your permission to use images/photos that may include your applicant.

I hereby grant permission to SHINE - Joplin to photograph and video me, and otherwise capture my image, and to make recordings of my voice. I further grant to SHINE - Joplin the right to reproduce, use, exhibit, display, broadcast, and distribute these images and recordings in any media now known or later developed for promoting, publicizing or explaining SHINE - Joplin and its activities and for administrative, educational or research purposes. Photographs, video images, and voice recordings are the property of SHINE - Joplin.

Signature of Parent/Guardian ( For Image Consent )^*

Date of Signature ( For Image Consent )^*

Signature of Applicant (if appropriate) - ( For Image Consent )

Date - ( For Image Consent )

SHINE - JOPLIN CONSIDERS ALL APPLICANTS REGARDLESS OF SEX, RACE, RELIGION, SEXUAL ORIENTATION, OR ETHNIC ORIGIN.

MEDICAL TREATMENT CONSENT

During volunteer days at SHINE - Joplin, we need the following consent signed in case a medical emergency should arise and your applicant need immediate medical care or emergency transport to a hospital.

The SHINE - Joplin staff has my consent to obtain medical assistance and treatment for both routine and emergency care for: (name of applicant)

Treatment includes but is not limited to the following:

● Ambulance transport to hospital or emergency care facility
● Hospital admission for in-patient care
● Administering of prescribed medications
● X-Rays
● Lab Work

This authorization is valid throughout application process and volunteer days worked in SHINE - Joplin.

Signature ( For Medical Treatment Consent )^*

Signature Date ( For Medical Treatment Consent )^*

Relationship with patient ( For Medical Treatment Consent )^*

VOLUNTEER CONSENT

During volunteer days at SHINE - Joplin, we may occasionally move to another facility for service projects and/or volunteer work.

The SHINE - Joplin staff has my consent to use vans, buses, and/or personal vehicles of SHINE staff and/or volunteers for transportation between activities for: (name of applicant)

This authorization is valid throughout application process and volunteer days worked in SHINE - Joplin.

Signature ( For Volunteer Consent )^*

Date of Signature ( For Volunteer Consent )^*

Relationship ( For Volunteer Consent )^*

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