Participate

Participant eligibility is dependent upon the program desired:

1. DTA participants are required to be no longer attending high school and have a DDD Coordinator. They are funded by the State to attend a Day Program (Day Treatment for Adults).

2. Drop-In participants must not require direct 1:1 supervision and be able to pay the monthly $40.00 fee or $2.00 per day. They are do not receive funding from the State to attend a Day Program.

3. ARCHKids participants are usually funded by the State but if not. we also accept a Private Pay arrangement.

4. Adventure Club participants must provide an attendant to accompany them if 1:1 supervision is required; otherwise the supervision ratio is approximately 1:4. They must be able to be 'on the go' for several hours, and be able to pay the vacation fees or have available respite hours.

Contact us to arrange a tour of our facilities and to discuss your needs. You can also fill out our Participant Form below and someone will be in touch with you to discuss it further. Or download and print it and fill it in by hand.

Read more about us in our ARCH Horizons Newsletters.

Participant Information Form

1Basic Info

2Important Contacts

3Contacts & Permissions

4Medical Information

5Medical Information

6Demographics

PARTICIPANT BASIC INFORMATION
Legal Name of Participant*
First Last
Nickname / Other name known by
First Last
Gender*
Date of Birth*
Are they still in school?
- Yes
- No
If Yes, name of school:
Please indicate which Program you are interested in:*
- ARCHKids Program (State Funded or Private Pay)
- DTA Program for Adults (State Funded)
- Drop-In Program for Adults (Private Pay)
Participant Address:*
Street Address Address Line 2 City State ZIP Code
Participant Email (if they have one):
Participant Home Phone no. :*
Participant Cell Phone no. (if they have one):
Who does the participant live with (List main head of household or caregiver):
Does the participant live in a group home?:
- Yes
- No

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Doctor's Name:
Name
First Last
Doctor's Address / Place of Practice
Street Address Address Line 2 City State ZIP Code
Phone
Health Insurance Carrier:
Member # / ID #
Desired Hospital (in an emergency situation the nearest facillity will be utilized):
Medication, Dosage & Time(s) Given:
Medication, Dosage & Time(s) Given:
Medication, Dosage & Time(s) Given:
Does the participant self-medicate or do you require medication adminstered during their time at ARCH?
Self-medicates?
- Yes
- No
Needs supervision to take medication during time at ARCH
- Yes
- No
Medical Treatment Authorization
I, (Guardian name) consent to medical treatment in any emergency situation. I understand that any affiliate of ARCH must seek medical advice/ and treatment as per the policies and procedures for any consumer attending ARCH programs on or off campus. In the event of an emergency situation I understand that I will be contacted and may need to arrive at the Medical Facility at my earliest convenience. I authorize medications to be administered by ARCH staff if stated above. (Please enter Guardian name. Enter Participant name if they are their own guardian):*
First Last
Guardian Signature (* Participant should sign if they are their own guardian)*
Date of Signature:*

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Participant Information Form

PARTICIPANT BASIC INFORMATION

IMPORTANT CONTACTS (Only fill in relevant boxes and if different from each other):

MOTHER

FATHER

OTHER (Family Member, other caregiver/provider)

GROUP HOME

CONTACTS & PERMISSIONS

Who is authorized to pick up participant in their own vehicle (please check all that are relevant and indicate names):

Media Consent:

Permission:

PARTICIPANT MEDICAL INFORMATION

Doctor's Name:

Does the participant self-medicate or do you require medication adminstered during their time at ARCH?

Medical Treatment Authorization

DEMOGRAPHICS:

We are required to ask the following questions for the purpose of securing funds and grants for our programs:

Thank you for filling in this form. If you have any questions please call us at ARCH 602-230-2226.