Alpine ABA Membership Form

Please fill out all required fields below (marked with an asterisk *) to begin your membership inquiry for Alpine ABA in South Burlington, VT.

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Applicant name *

First

Last

Applicant date of birth *

Applicant email *

Applicant phone *

Applicant address

Is applicant their own guardian? If "no", please enter guardian's Name, Address, Phone, Email, and Relationship to applicant. *

Any other team members that would support you in becoming a member that you would like to receive information about this? If so, please enter their full name and email here.

Please list all health and safety information we may need to know (ie: allergies, mobility, etc.) *

How do you prefer to communicate with others? *

How do you prefer to be communicated with? *

Do you enjoy watching movies? *YesNoUnsure

Do you enjoy playing pool/billiards? *YesNoUnsure

Do you enjoy dancing with others? *YesNoUnsure

Do you enjoy listening to music? *YesNoUnsure

Do you enjoy playing cards or boardgames? *YesNoUnsure

Do you enjoy doing puzzles alone? *YesNoUnsure

Do you enjoy doing puzzles with others? *YesNoUnsure

Do you enjoy yoga? *YesNoUnsure

Do you enjoy going for walks? *YesNoUnsure

Do you enjoy swimming? *YesNoUnsure

Do you enjoy basketball? *YesNoUnsure

Do you enjoy soccer? *YesNoUnsure

Do you enjoy cooking or baking? *YesNoUnsure

Do you enjoy art projects, coloring, or drawing? *YesNoUnsure

Do you enjoy painting? *YesNoUnsure

Do you enjoy writing? *YesNoUnsure

Do you enjoy reading alone? *YesNoUnsure

Do you enjoy reading with others? *YesNoUnsure

Do you enjoy using technology (tablet, computer, etc.)? *YesNoUnsure

List 3 activities that you like to do *

List 2 activities that you never want to do / prefer not to do *

List 3 of your favorite foods *

If you like to cook or bake, WHAT do you like to cook or bake?

What is your favorite color? *

Do you have any favorite movies or TV shows (if so, what)? *

Who are the people that support you in reaching your goals? *

List 3 types of exercises you enjoy (dancing, yoga, walking, hiking, skiing, sports, etc.) *

What is something you would like to learn to do? *

Do you like to go outside? If so, what do you like to do outside? *

Do you have a job? If so, please tell me about it! *

Would you like a job, or a new job? If so, please tell me more! *

Do you like animals? If so, what kinds? *

Do you have any pets? If so, what animals? *

What are some of your favorite places to go in the community? *

If you like art, please tell me about some of your favorites (drawing, painting, etc.)

What is your favorite season (winter, spring, summer, or fall)? *

Are there any activities you enjoy that we have not asked about?

Is there any other information you would like us to know?

What are some goals you or your team have for you joining Alpine ABA Community and Learning Center?

Any questions you have for the staff at Alpine ABA Community and Learning Center?

Anything else we should know about you that would help us best support you during your time at the Alpine ABA Community and Learning Center?

Thank you for filling out our initial intake packet. The next step is to have an in-person meeting and tour if it has not already occurred (20-30 min). Please list the dates and time that would work for you and we will be in touch within 3 business days to set up a tour. *

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