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808-737-7995
The Arc in Hawaii
Inclusion. Involvement. Independence.
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808-737-7995
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ABOUT US
History of The Arc in Hawaii
Core Values and Operating Principles
Strategic Plan
Board of Directors
SERVICES
Eligibility for Services
Adult Health Service
Residential Services
ADVOCACY
EMPLOYMENT
DONATE
FORMS
Application For ADH Services
Application for Residential Services
CONTACT US
HOME
ABOUT US
History of The Arc in Hawaii
Core Values and Operating Principles
Strategic Plan
Board of Directors
SERVICES
Eligibility for Services
Adult Health Service
Residential Services
ADVOCACY
EMPLOYMENT
DONATE
FORMS
Application For ADH Services
Application for Residential Services
CONTACT US
Application For ADH Service
You are here:
Home
Application For ADH Service
Application For ADH Service
ADH Application for Services
Applicant’s Name:
(Required)
First
Middle
Last
Date of Birth
MM slash DD slash YYYY
Sex
Male
Female
Social Security #
Citizenship
Medicaid #
Phone
(Required)
Alternate phone
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Current Living Situation (Check):
Family
Domiciliary Home for Developmentally Disabled Adults
Currently Occupying HUD Assisted Unit
ICF/MR-C Home
Foster Home
Other
Other
Legal Guardian’s Name
Relationship/Title
Phone
Email Address
(Required)
Case Manager’s Name
Agency
Phone
Email Address
(Required)
Family Information
Father’s Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Work phone
Cell phone
Email Address
(Required)
Mother’s Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Work Phone
Cell Phone
Email Address
(Required)
Applicant’s Condition(s) (Check all that apply)
Intellectual/Developmental Disability (ID/DD) (diagnosis)
Autism
Cerebral Palsy
Epilepsy
Learning Disability
Visual Impairment (degree of impairment)
Hearing Impairment (degree of impairment)
Other Diagnosis
Other Diagnosis
Adaptive Protective Equipment Needed (e.g. furniture, wheelchair, crutches, etc.)
(Required)
Education, Training, and Employment History (list last school or program first)
1.
To
MM slash DD slash YYYY
From
MM slash DD slash YYYY
2.
To
MM slash DD slash YYYY
From
MM slash DD slash YYYY
3.
To
MM slash DD slash YYYY
From
MM slash DD slash YYYY
How did you hear about our services (i.e. Case Mgr, web site, ad, etc.)?
Person Completing Application:
I certify that the information provided is complete and accurate.
Name
Phone
Relationship to Applicant
Signature
Date
MM slash DD slash YYYY
Applicant’s Signature
Date
MM slash DD slash YYYY
Applicant’s Name
Length of Day
Full Day
Half Day
PA (hourly)
Days Attending
Monday
Tuesday
Wednesday
Thursday
Friday
Other
Fee for Services Daily Rate
(To be paid in advance, on the first of each month)
29548
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