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Program*:  
           

Applicant Information

SSN*:     (Social Security Number)
First Name*:
Last Name*:
Middle: 
Address*: 
City*:
State*:
Zip*:
County*:
Date of Birth*:

Place of Birth
Hospital: 
City:
State:
County:

Applicant's Family

Please provide family background information.

Father
SSN:     (Social Security Number)
First Name:
Last Name:
Middle:
Address: 
City:
State:
Zip:
Phone:
Date of Birth:
Place of Birth - Hospital: 
Place of Birth - City: 
Place of Birth - State: 
Occupation: 
Where Employed? 
Business Phone: 
Business Fax: 

If deceased, give date and cause:

Date: 
Cause: 

Mother
SSN:     (Social Security Number)
First Name:
Last Name:
Middle:
Maiden Name:
Address: 
City:
State:
Zip:
Phone:
Date of Birth:
Place of Birth - Hospital: 
Place of Birth - City: 
Place of Birth - State: 
Occupation: 
Where Employed? 
Business Phone: 
Business Fax: 

If deceased, give date and cause:

Date: 
Cause: 

Siblings

Click "Add Sibling" to provide information on the applicant's siblings.
Please include deceased siblings.

Any medical problems of siblings? (please explain)




Parents' Marital Status

Father
Status:  

Marriage
Date: 
City: 
State: 

Separation
Date: 
City: 
State: 

Divorce
Date: 
City: 
State: 

Remarriage
Date: 
City: 
State: 
Spouse: 

Mother
Status:  

Marriage
Date: 
City: 
State: 

Separation
Date: 
City: 
State: 

Divorce
Date: 
City: 
State: 

Remarriage
Date: 
City: 
State: 
Spouse: 


Guardianship

Name(s): 
Address: 
City: 
State: 
Zip Code: 
Home Phone: 
Work Phone: 
When was guardian appointed? 
Where was guardian appointed (location of court)? 
Address: 
City: 
State: 
Zip Code: 
Is this person(s) legal guardian of? 
           


Applicant's Medical History

Diagnosis: Include the diagnosis of developmental disabilities and physical health related issues.

Present Medications: Reasons for and dosages.

Surgeries: Provide date for each surgery.

Chicken Pox: If the applicant has had chicken pox, please indicate age or date:

Allergies: If the applicant has allergies, please describe:

Visual Impairment: Please describe any visual impairments and the cause:

Hearing Impairment: Please describe any hearing impairments and the cause:

Seizure Disorder: Please describe any seizure disorder and medication used:

Mental/Emotional Disorder: Please describe and provide psychiatric diagnosis if available:

Other: Describe any additional medical/information you feel is important in our consideration of this application:

Applicant's Educational History

Click "Add School" to provide information on the applicant's education history.


Applicant's Vocational/Post Secondary Education

Click "Add School" to provide information on the applicant's education history.


Applicant's Employment Record

Click "Add Employer" to provide information on the applicant's employment history.



Applicant's Residential Placements

Click "Add Placement" to provide information on the applicant's residential placements.



Religious Preference

Applicant's: 
Father: 
Mother: 


Add a Photo

If you would like you may attach a photo of the applicant to this form.

Further Correspondence

To whom should futher correspondence about this application be referred?

Name: 
Phone: 
Relationship to Applicant: 
Address: 
City: 
State: 
Zip Code: 
Name of person completing application:    Same as above
Phone: 
Relationship to Applicant: 
Address: 
City: 
State: 
Zip Code: 



Additional Information

School reports (if applicant has completed school within past 5 years)-- Include the applicant’s Individual Educational Plan (IEP); achievement tests; any physical, occupational, or speech therapy, if applicable; physical education; counseling, if applicable; and teacher observations and recommendations.

Psychological report -- This should include IQ tests, functioning levels, personality tests, learning levels, and mental age. This report must be done within the last three years of the date of application.

ICAP (Inventory for Client & Agency Planning) Report: Required for Illinois CILA applicants; optional for others.

Medical report -- This report must include a recent physical examination or summary (within a year of the date of application), any significant past medical history, any current health problems, and any medications prescribed with the reason for the medications.

Social History -- If available, please submit.

Report from any residential and/or work placements -- This report should include such things as the applicant’s adjustment in the placement, peer and staff relationships, and the type of populations served in the facility and/or work setting. The work report should include the types of work accomplished, ability to complete work assignments, and relationships with peers and staff. The last 2 year’s ISP’s (Individual Service Plans) should also be included.

Application Process

Once the completed application form and all the above reports are received, the material will be reviewed by the Admissions Team for their recommendation. We will then contact you to set a date and time for the personal interview, which is a requirement for application to our programs. An on-site evaluation of several days’ length may also be required prior to a final admission decision.

Upon acceptance of the applicant for admission to St. Coletta, requirements for admission include submission of: a certified copy of the applicant’s birth certificate; an original Social Security card and Medicaid (T-19) card; Advanced Medical Directives Form (if completed), Health Care Power of Attorney (if completed), the court order of appointment of a legal guardian, if applicable; any life insurance or burial trust information, and other forms requesting specific information. These forms must be submitted before an admission date can be set.

If the Admission Team votes not to accept, you will be notified, with recommendations given for alternate resources. You have the right to appeal that decision to the Vice-President of Residential Services. The decision of the Vice-President of Residential Services may also be appealed to the President/CEO, whose decision is final.

Admissions Coordinator
St. Coletta of Wisconsin, Inc.
W4955 Highway 18
Jefferson, WI 53549

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