CareerZ Registration

Register for our upcoming CareerZ event

CareerZ launches October 1 and runs Monday through Friday, 9:00 AM to 3:00 PM. This ongoing program serves individuals aged 22+ with intellectual and developmental disabilities (including autism), offering support for education, employment, and career changes. Services are covered through MPW and SCL waivers, with private pay available at $14.48/hour. Once your application is submitted, our team will follow up to review details and next steps.

Applicant Information

Applicant's First Name

Applicant's Last Name

Applicant's DOB

Applicant's Age

Applicant's Sex

Applicant's Height

Applicant's Weight

Address

City

State

ZIP

Applicant's T-Shirt Size

Is the applicant currently involved in school, a day program, supported employment, homeschooling, or another program? If so, please list the name.

Parent/Guardian Information

Primary Parent or Guardian’s First Name

Primary Parent or Guardian’s Last Name

Primary Phone

Primary Parent or Guardian Email

Primary Parent or Guardian Employer

Secondary Parent or Guardian’s First Name

Secondary Parent or Guardian’s Last Name

Secondary Parent or Guardian’s Phone

Secondary Parent or Guardian’s Email

For applicants 18+ years, has the applicant been adjudicated incompetent in court with an appointed legal guardian? If yes, who is their legal guardian? If no or under 18, type "no".

Program Funding

Will you be using Private Pay or Waiver?

Is the applicant on the Michelle P Waiver Waitlist, meaning you have applied for the waiver but have not yet been approved?

If using Respite (Michelle P Waiver), what is your case manager's name?

Case manager's Agency Name

Case manager's Phone Number

Case manager's Email

Medical & Diagnostic Information

Applicant's Primary Diagnoses

Please specify any additional diagnoses that were not listed above

Has the applicant been hospitalized for any of the reasons listed above? If yes, please describe.

Is the applicant on medication(s)? If yes, please note the name(s), purpose(s), and how often they take them. If none, enter N/A.

Applicant's allergies (please note severity as well). If none, enter N/A.

Does the applicant carry an epi-pen?

Yes No

Physician's Name

Physician's Phone Number

Learning Styles & Support Needs

Does the applicant learn best through visual means, such as when their sense of sight is engaged? Please provide any details that will help us teach using this learning style.

Does the applicant learn best through auditory means, such as when their sense of hearing is engaged? Please provide any details that will help us teach using this learning style.

Does the applicant learn best through kinesthetic means, such as when their senses of touch, movement, or motion are engaged? Please provide any details that will help us teach using this learning style.

Based on the applicant’s skills and behaviors, what level of supervision is needed throughout most of the day? Please consider how they respond to new situations, unfamiliar people, and transitions between activities.

Staff Preference (Note: While we will do our best to accommodate, preferences are not guaranteed)

Communication & Comprehension

Can the applicant ask for help?

Yes No

Can the applicant communicate an illness or pain?

Yes No

Which type of schedule works best for the applicant?

How do the applicant handle transitions? Please explain what types of transitions are difficult and techniques or reinforces to help her/him be successful.

Daily Living Support

What types of ambulation needs does the applicant have? If none, select Not Applicable.

Mealtime capabilities and support needs (check all that apply)

Does the applicant have any dietary needs or food allergies? (gluten free, no sugar, no pork, etc.) If none, enter Not Applicable

What level of assistance does the applicant require with toileting?

How does the applicant communicate that they need to use the bathroom?

How often does the applicant typically use the bathroom?

Behavior & Emotional Support

Please explain any behaviors checked above and common antecedent or triggers, resulting behavior, and consequences used at home, in therapy settings, and in the community.

Please list any other behaviors not mentioned above that we should be aware of so that we can provide the level of support needed. If none, enter N/A.

Do any of the above listed behaviors affect the applicant’s daily life? If so, how? If none, enter N/A.

Please list any observed obsessive-compulsive behaviors. If none apply, please enter N/A.

Does the applicant have a behavior support plan in place? If so, we request a copy of that plan during the application process.

Yes No

Please upload a copy of your teen/young adult's behavior plan (if applicable)

Behavior Therapist's First Name

Behavior Therapist's Last Name

Behavior Therapist's Phone Number

Behavior Therapist's Email

Behavior Therapist's Agency Name

Has the applicant had any involvement with law enforcement? (ex: school, home, or community setting) If so, please explain. If not, enter no.

Which emotional responses apply to the applicant? (Select all that apply)

What situations, objects, or experiences tend to scare or upset the applicant?

What strategies or comforts help soothe the applicant during times of distress (e.g., when they are sad, afraid, hurt, or upset)?

How does the applicant react to pain?

Please note any other sensitivities the applicant has and provide any additional relevant information.

Reinforcers & Motivation

Which of the following reinforcers are effective for the applicant? (Select all that apply)

Please describe any additional reinforcers not listed above.

How is reinforcement typically delivered?

Do you use a reward system as part of the behavior plan? If so, please describe it so we can use these during our programming. If none, enter N/A.

Interests & Enjoyment

What best describes the applicant’s activity level and attention? (Select all that apply)

Has typical attention span and level of activity for his/her age Has a short attention span Less active / needs motivation to participate Overactive Easily distracted by sights, sounds, people, etc.

How do you manage the applicant’s activity level and motivate them to participate?

Please list any activities the applicant dislikes or avoids. Be as specific as possible.

What indoor activities does the applicant enjoy? (e.g., painting, acting, board games)

Which types of outdoor activities does the applicant enjoy? (Select all that apply)

Ball (bowling, volleyball, ball toss, basketball, kick ball, soccer, etc.) Water (swimming, slip & slide, water balloons, sprinkler, water relays, etc.) Sensory (bubbles, free play with lights, sounds, smells, textures, balance beams/balls) Exercising (sit-ups/push-ups, hiking, jump rope, riding bikes, stretching, trampoline, walking) Group (duck-duck-goose, kickball, musical chairs, parachute games, relay races, volleyball, etc.) Individual in a group setting (yoga, petting animals, dancing, building, aerobics, etc.) Individual (corn hole, swinging, frisbee, hopscotch, playground, putt-putt, etc.)

Help Us Support You Better

Are there any occupational or physical therapy goals the applicant is currently working on that would be helpful for us to know? If none, enter N/A.

What are the applicant's strengths?

What would you like for the applicant to get out of her/his experience at Zoom Group Inc?

Is there anything else we should know about the applicant to make their experience a great one? The more we know about her/his likes/dislikes, skills, needs, behaviors, the better we can serve her/him.

How did you hear about Zoom Group?

If you checked other, please specify here.