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LOH 2012 PDF

LOH 2012 PDF

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Published by Julie Lyles Carr

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Published by: Julie Lyles Carr on Feb 01, 2012
Copyright:Attribution Non-commercial


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Legacy of Hope Austin toll free 866-HOPEATXwww.legacyofhopeaustin.org 
Family Application Form
*please print clearly 
Date________________Please check the box for the program for which you are applying:
Mother/Guardian’s Name:___________________________________
Father/Guardian’s Name:____________________________________
 Home Phone_____________________Cell Phone__________________Work Phone_____________Address______________________________________City_____________State______Zip________Email_________________________________________________
Child’s Name_________________________________________Age______________DOB___/___/___
 Diagnosis___________________________________________________Briefly describe the special needs of your child and describe some of their learning challenges: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
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Legacy of Hope Austin toll free 866-HOPEATXwww.legacyofhopeaustin.org 
Please describe your child’s
school history, including details that would be important for ourteam to know in order to provide the best care for your child: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________
Sibling’s name:_____________________Age:_____________
Sibling’s name:_____________________Age:_____________
Sibling’s name:_____________________Age:_____________
Sibling’s name:_______
The following information is collected strictly for Legacy of Hope Austin for statistical purposes. Thisinformation helps Legacy of Hope Austin address questions grantees and donors may have regarding diversity,socio-economic status, etc. Your information will be kept confidential. Thank you for your willingness and honesty 
Family Ethnicity:____________2.
One or Two Parent Household:____________3.
Marital Status:4.
Total number of children in family (including child(ren) with special needs):_____________5.
Family’s Income Level (
approx): ____________________________6.
Mother’s Highest Completed Educational Level:
Father’s Highest Completed Educational Level:
 ______________________________Do you currently receive services from the Division of Services for People with Disabilities? Y/NDo you currently receive aid from your school district for their lunch program or any othersupport program? Y/NPlease explain how you think this program might strengthen your family: ______________________________________________________________________________Please indicate, between 1 and 10, the average stress level on your family as a whole: ________
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Legacy of Hope Austin toll free 866-HOPEATXwww.legacyofhopeaustin.org 
Release Form for Media Recording
I, the undersigned, do hereby consent and agree that
Legacy of Hope Austin
, its employees, or agents have theright to take photographs, videotape, or digital recordings of me and/or my child ________________________ andto use these in any and all media, now or hereafter known, and exclusively for the purpose of furthering themission of 
Legacy of Hope Austin
and its programs. I further consent that my name and identity may be revealedtherein or by descriptive text or commentary.I do hereby release to
Legacy of Hope Austin
, its agents, and employees all rights to exhibit this work in print andelectronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may haveto control the use of my identity or likeness in whatever media used.I understand that there will be no financial or other remuneration for recording me, either for initial or subsequenttransmission or playback.I also understand that
Legacy of Hope Austin
is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result.Name: Date:Address:Phone:Witness for the undersigned:Signature:

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