Cell Phone Start Date

Application for Admission to The Summerhouse

Completing the Application

Thank you for your interest in The Summerhouse.

Please complete this application and return to the following items: Recent photo of the applicant (photo will not be returned) Completed application form

Medical history

Most recent psychological, psychiatric and educational evaluations Behavior plan (if applicable)

Additional helpful information you feel is relevant to understanding the history and needs of the applicant

Once a complete application packet has been received, The Summerhouse Admission Committee will review the information carefully to determine the placement availability and suitability of each candidate. You will be notified of the outcome of this process. If you have any questions during this application process, we encourage you to contact us. We look forward to reviewing your application.

www.summerhousehouston.org ****@******************.*** 1814 Columbia Street, Houston, TX 77008 phone: 832- 200- 6158 fax: 832- 200- 6159 Application for The Summerhouse

Today’s Date

Ideal start date

Applicant’s full

name:

Date of birth:

Sex:

Address:

Home Phone:

Height: Weight:

SS#:

Siblings

(name, age):

Parent/Guardian Information

Parent/Guardian

Name:

Home phone: Cell phone:

Email:

Address:

Occupation/

Company:

Work Phone:

Parent/Guardian

Name:

Home phone: Cell phone:

Email:

Address:

Occupation/

Company:

Work Phone:

www.summerhousehouston.org ****@******************.*** 1814 Columbia Street, Houston, TX 77008 phone: 832- 200- 6158 fax: 832- 200- 6159 Previous or Current Academic Settings and Programs Please check all those settings/situations in which the applicant has participated. Day Habilitation

Employment

Public School

State School

Group/Family Care Home

Independent Living Situation

Private School Other (Explain)

Program Name:

Dates:

Address:

Type (see above):

Person to contact

for more info:

Phone or

email:

Reason for

leaving:

Program Name:

Dates:

Address:

Type (see above):

Person to contact

for more info:

Phone or

email:

Reason for

leaving:

Program Name:

Dates:

Address:

Type (see above):

Person to contact

for more info:

Phone or

email:

Reason for

leaving:

www.summerhousehouston.org ****@******************.*** 1814 Columbia Street, Houston, TX 77008 phone: 832- 200- 6158 fax: 832- 200- 6159 Tuition policy

• Tuition (5 days/week /year round) - $1500.00/month.

• Monthly activity fee - $60.00

Payment is due in full prior to or on the 1st of each month. A late fee of $5/day will apply if tuition is not paid by the 5th of each month unless prior arrangements have been confirmed with the Executive Director of The Summerhouse. A deposit of one- half of one month’s tuition ($750.00) is due at the time of enrollment. Upon 30 days written notice, the amount will be applied to the last month’s tuition. We do accept CLASS, HCS and TxHml funds. Please call for details. I have read and understand the financial commitment to The Summerhouse as a part of enrollment. Signature:

References

Please list references for the person who will be financially responsible for enrollment. Personal Reference (friend, neighbor etc.)

Name:

Home phone: Cell phone:

Address:

Professional Reference (colleague, fellow worker etc.) Name:

Home phone: Cell phone:

Address:

www.summerhousehouston.org ****@******************.*** 1814 Columbia Street, Houston, TX 77008 phone: 832- 200- 6158 fax: 832- 200- 6159 Applicant Background

Please answer the following questions with as much candid detail as is possible to allow the Admissions Committee to support an informed decision that supports the needs of your child. Describe his/her general health including special medical problems or physical disabilities: Describe his/her communication abilities and style: Describe his/her social/emotional state MOST of the time (withdrawn, hyper- verbal, even- tempered etc): Are there particular triggers that dramatically alter this state? Describe his/her preferred social state (with peers, family, alone, with particular people): Describe his/her self- help skills (what most others do daily to help him/her): Does he/she toilet independently? Yes No. If not, please explain: Describe his/her daily routines as well as leisure activities: www.summerhousehouston.org ****@******************.*** 1814 Columbia Street, Houston, TX 77008 phone: 832- 200- 6158 fax: 832- 200- 6159 Applicant Background continued

What do you see as his/her functional disabilities: What level of awareness does s/he have of his/her disabilities: Describe his/her aptitudes, interests and strengths? Does s/he ever exhibit aggressive or injurious behavior such as hitting, pinching, biting, screaming to him/herself or others? Describe.

Describe activities and situations that s/he strongly dislikes. How does s/he express this dislike? Describe your goals and expectations for him/her. What do you hope The Summerhouse can accomplish? www.summerhousehouston.org ****@******************.*** 1814 Columbia Street, Houston, TX 77008 phone: 832- 200- 6158 fax: 832- 200- 6159 Physician

Medical History

Name

Phone

Address

Other specialists who

have treated applicant

Allergies

Medications

Food, pollen, insect bites,

skin contacts, substances

etc. Reaction and

treatment?

Medication/injection for

allergy treatment.

Prescribed by:

Name, dosage, frequency.

Medication –please list all medications being taken by applicant Name Dose/Frequency Prescribed by: When prescribed: Please share any additional information that could influence the ability of The Summerhouse to work successfully with the applicant and to ensure their care, health and well- being while enrolled in The Summerhouse.

The health and medical information provided here is correct to the best of my knowledge. Signature of Parent or Guardian Date

Signature of Parent or Guardian Date

www.summerhousehouston.org ****@******************.*** 1814 Columbia Street, Houston, TX 77008 phone: 832- 200- 6158 fax: 832- 200- 6159 Review and Signature

Please note that the application and all supplemental materials, must be submitted in full before it can be reviewed by the Admissions Committee.

It is the policy of The Summerhouse to enroll clients of any race, color, and national or ethnic origin. All information submitted as a part of this application will remain confidential and will be used for the sole purpose of determining admission. No portion of this application information will be shared with any parties outside of The Summerhouse.

Please review and sign once all application content has been confirmed and completed. Every candidate for enrollment is considered based on his or her needs, skills and overall “fit” based on the mission, focus, resources and cohort of members at The Summerhouse. Each candidate is evaluated individually, and we review suitability on a case by case basis. Accurate and complete information regarding the applicant’s background, abilities and needs is required to make an accurate assessment. We ask that parents/guardians complete the application thoroughly and candidly. Additional information may be requested from a third party who has served as a therapist, teacher or aid within the past 12 months. Additional information in regard to “fit” is gathered during a visit to The Summerhouse when the applicant will participate in routine daily activities.

I affirm that the preceding information is a complete and accurate statement of all the facts and circumstances relative to the application for enrollment in The Summerhouse. We, the undersigned, do give our permission for The Summerhouse to contact any and all of the references, programs, schools, and professionals listed in this application. Signature of Parent/Guardian Date

Signature of Parent/Guardian Date

Signature of person completing application if other Date than parent or guardian; please note relationship

Contact this candidate