Rainbow Acres Admission Inquiry Application

*Criteria for Admission to Rainbow Acres is located on our website.
Please complete this short questionnaire to help Rainbow Acres staff gain a general idea about the special needs person interested in living at Rainbow Acres. The full application, if requested, will require more detailed information.
Please complete this online preliminary application for prospective residents of Rainbow Acres. (Information provided will always remain confidential)

Prospective Resident Name:*
Address:*
City:*
State:*
Zipcode:*
Place of Birth:*
Gender:*
Age:*
Cognitive Age:*

Name and Relationship of Person Completing Application

Name:*
Relationship to Prospective Resident:*
Guardian Name:*
Address:*
City:*
State:*
Zip:*
Phone:*
Preferred Method of Contact:*

Prospective Resident Info

Primary Disability:*
Physical Disability(s):*
Medical Conditions:*
Seizures:*
Current Psychological Evaluation: * Yes Date: No
Check all that apply: * Glasses Hearing Aid Dental Appliance Cane Walker Wheelchair
Interacts Well With Others: * Yes No
Has Worked in the General Community: * Yes No
Cooperation With/Consideration of Others: * Yes No
List Things That Cause Anxiety:
History of Harm to Self or Others: * Yes No
If Yes, Please Explain:
Independent Personal Care & Grooming: * Yes No With Assistance: Yes
Appropriate Behavior When in Public: * Yes No
Appropriate Behavior With the Opposite Sex: * Yes No
Is Applicant Able to: * Read Write Tell Time Handle Money
Need for Supervision: * Constant Moderate Can be left alone for short periods
Listens to & follows directions: * Yes No
Controls Temper: * Yes No
Respects property of others: * Yes No
Has the Applicant ever lived in a special needs community before? * Yes No

*Thank you for your interest in Rainbow Acres. When this application has been reviewed, the Director of Admissions will contact you by phone or email to answer any questions you may have.

* By checking this box and submitting this form, I hereby certify that I have read and understand and agree with the terms and conditions of the Rainbow Acres Admission Inquiry Application.