APPLICATION FOR ADMISSION

Date application received:  _____/_____/_____ (MMI use only)

Applicant’s Personal Data:

Name: _____________________________________________________________________________________________

Address: _________________________________________ City: ____________________ State: ______ Zip: _________

County: _____________________________ Township: ___________________________ Birth date: _____/_____/_____

Residential Setting (i.e., independent, with family, etc.): _____________________________________________________

Phone: _(_________)_________________________ Social Security #: __________________________ Sex: ___M ___ F

Emergency Contact Person: __________________________________ Phone: _(_________)_______________________

Address: _________________________________________ City: ____________________ State: ______ Zip: _________

 Educational History: (list schools, graduation dates, degrees, or certificates)

 __________________________________________________________________________________________________

 __________________________________________________________________________________________________

 Employment History/Vocational Training:

Eligibility for Service Participation: (Proof of eligibility is required to enter MMI’s services.  Please attach documentation of barrier to employment or disability.)

Employment Eligibility:

Have you (applicant) ever been convicted of a crime? _____ Yes _____ No    If yes, please describe:

__________________________________________________________________________________________________

Are there any felony charges pending against you? _____ Yes _____ No    If yes, please describe:

__________________________________________________________________________________________________

Are you legally eligible for employment in the United States? _____ Yes _____ No 

(Proof of citizenship or immigration status will be required before obtaining employment.)

Do you have transportation available to attend work or training?  _____ Yes _____ No   

If yes, please designate: _____ private vehicle _____ public transportation _____ need aide ___________________ other

Guardianship Status:

Own Guardian: _____ Yes (go to next section) _____ No (please complete information below)

Guardian: __________________________________________________________________________________________

Address: _________________________________________ City: ____________________ State: ______ Zip: _________

Phone: _(_________)____________________________ Email: _______________________________________________

Scope of Guardianship: _______________________________________________________________________________

Medical Information: 

• If you (applicant) have a serious medical condition, attach recent physical report.
• Medication is administered one time a day (Noon) at MMI.
• Will MMI need to administer medication? _____ Yes _____ No

-          If yes, a physician’s order is required and a supply of medication should be submitted.

• Seizure disorder? _____ Yes _____ No 

-          If yes, frequency: _____________________________________________________________________

-          Action to be taken: ____________________________________________________________________

• Do any medical protocols need to be followed? _____ Yes _____ No 

-          If yes, please attach copy of protocols.

 Other Considerations: (Information MMI staff needs to know to provide a safe environment.)

 __________________________________________________________________________________________________

 __________________________________________________________________________________________________

 Do you (applicant) have a Behavior Program? _____ Yes _____ No  If yes, please attach.

 All application information I have provided is true to my knowledge.  I authorize MMI to investigate all statements contained in this application to determine my eligibility for participation.

 Signature: ____________________________________________________________________ Date: _____/_____/_____

(If not completed by participant, the individual completing application must sign and indicate relationship to participant.)

 Referring Agency: ____________________________________________________ Date of Referral: _____/_____/_____

 Agency Representative (signature required): ______________________________________________________________