Barrier Breakers Unlimited
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BBU Enrollment Form
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Enrollment Applicant Information
Full Name:*
Preferred Name / Nickname:
Date of Birth:*
Age:
Gender Identity:*
—Please choose an option—
Male
Female
Prefer not to say
Other
Primary Diagnosis or Learning Difference (if known):
School/Program Currently Attending (if any):
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Parent/Guardian Information
Parent/Guardian Name(s):*
Relationship to Applicant:*
Phone Number:*
Email Address:*
Mailing Address:*
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Support & Services Information
Does the applicant currently have an:
IEP
504 Plan
None
Has the applicant received:
Special Education Services
Vocational Rehab Services
Other Transition Support
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Goals & Interests
What are your goals for participating in BBU / LaunchPoint?
What areas does the applicant need support in?
Life Skills (cooking, cleaning, money management)
Job Skills / Vocational Training
Social/Emotional Skills
Communication
Independent Living
Community Integration
Other:
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Upload Required Documents
Upload a copy of the participant’s IEP / 504 Plan (PDF or image, max 3 MB):
Upload proof of age (state ID, school ID, etc., max 3 MB):
Upload any relevant assessments or evaluations: (max 3 MB)
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Emergency Contact
Name:*
Relationship:*
Phone Number:*
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Consent & Acknowledgements
I consent to participate in BBU programming.
I agree to the terms outlined in the orientation packet.
I understand this application does not guarantee immediate enrollment and that space may be limited.
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