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Yarmouth Life Skills
Application

Please answer all questions as completely as possible. All information is confidential and for use of Yarmouth Life
Skills Staff only. Successful applicants will have an intellectual disability and MUST be 18 years old or older. 

Applicant Information

Parent/Caregiver Information

Present Living Situation

Select an option:

Diagnosis Information

Check all that apply:

Current Medications

Choose all that apply:
Will medicaton need to be adminstered during the day?

Allergies

Is an EPIPEN required?

Level of Developmental Disability

Select one:

Mobility

Select one:

Literacy Skills

Choose all that apply:

Independance

Choose all that appy:

Self Care

Choose all that apply:

Personal Interests

Choose all that apply:

Behaviour Challenges

Please list and indicate how these challenges can be successfully handled

Past Day Activities

Please list details regarding any past day activities, including program and school names and contact person(s)

Days of the Week Required

Choose all that apply:

Comments

Additional comments which may be helpful to staff

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