Application for The Arc’s DDA Waiver Services | The Arc Prince George's County

Services applied for*

Meaningful Day (Employment, Community Development Services, or Day)

Living Options (Personal Support, Supported Living, or Community Living)

Supported Services (Behavior Support Services, Respite Care, Assistive Technology Services)

Other - Please List Below

Other Please List

Support Services

Assistive Technology and Services

Behavior Support Services

Environmental Assessment and Modification

Nursing Support Services

Remote Support Services

Respite Care

Transportation with Employment Supports

Personal Information

Name

First Last

Phone*

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Education

Please Indicate Name of School

City

State

Graduation Date

Employment/Vocational

Please indicate the name of your employer.

Employment/Vocational Schedule

Day Support/Program

Please indicate the name of your current provider and schedule.

Health/Medical Information

Primary Diagnosis

Additional Diagnosis

Additional Diagnosis Information

Other Medical Information

Medications (Prescription and Over the Counter)

Please indicate medication, dosage, route, frequency, and purpose

Seizure Disorder

Types of seizure and triggers

Diet Restrictions/Adaptive Dishes or Utensils/ Feeding assistance

Food, Environmental or Medicine Allergies

Guardian/Caregiver Information

Please indicate name and relationship to applicant.

Guardian Caregiver Name

First Last

Relationship

Legally appointed guardian's name

First Last

Relationship

Legal Status

Check all that apply

Legally Appointed Guardian

Own Guardian

Current Living Situation*

Check all that apply

Lives Alone

Lives With Family

Lives With Someone Other Than Immediate Family

Other, Please explain

Additional Living Situation Info

Emergency Contact Information

Other than parent or guardian

Name*

First Last

Phone*

Email

Financial Information

Complete only if you are seeking residential services - Otherwise, click button for NEXT below.

Is the individual receiving government benefits?

SSI, SSD, or SSA

SNAP

Medicaid or Medical Assistance

Medicare

Other - Please list below

Other

Representative Payee's Name

First Last

Administrative Declaration

Name of Person Completing This Form

First Last

Signature

Date

About The Arc PGC

Events & News

Staff & Board

History

Stories

Get Involved

Publications

Title VI Implementation

Adult

Children & Youth

Project LIVE

Resources

Employer Resources

Job Seeker Resources

Careers at The Arc

DDA Waiver Services