1 Maguire Rd. Lexington, MA 02421 Phone: (781) 860-1900 Fax: (781) 860-1920 www.mghaspire.org

v2.19

Additional Info Form for Returning Participants(A full application is not required if applied or participated within the last year)

Please Submit Your Application and Payment via: EMAIL PHONE

FAX MAIL

MGH Aspire accepts checks payable to MGH Aspire and sent to the address above or a credit card over the phone at 781-860-1900.

You will receive a confirmation email within 5 business days of MGH Aspire receiving your form. Applications

Please contact us at 781-860-1900 or email us at mghaspire@partners.org if you have any questions.

Copies of staff background check procedures, healthcare and discipline policies are available upon request. .

Additional Info Form for Returning ParticipantsMedical Record Number (MRN) on this form Program Interest Sheet (separate document)Updated Resume (MGH Aspire Works program only)New or Neuropsychological or Psychological Evaluation (if available)New or updated IEP or 504 (if available and you are still in school)Releases of Information (as applicable)*Applicants 18 years and older need to submit releases for parent/guardian communication tooccur.

our Lexington office upon receipt of the complete application packet. These interview sessions are designed to match applicants to peer groups; our goal is to determine the best placement for you or your child.

Financial assistance is awarded based on financial need and fund availability. The financial aid application can be downloaded from our website.

Thank you for applying to the MGH Aspire program!

are accepted on a rolling basis until programs are full. Candidates will be scheduled for an interview session at

mghaspire@partners.org 781-860-1900781-860-1920MGH Aspire1 Maguire Road

Lexington, Massachusetts 02421

Thank you for your interest in MGH Aspire programs. Please be sure to save this PDF file to your desktop/laptop computer and then open in Adobe Acrobat Reader. You may either enter your responses directly onto this form or you may handwrite responses on the printed form. A complete application includes:

P a g e | 2 v2.19

1 Maguire Road, Lexington, MA 02421 | Tel 781-860-1900 | Fax 781-860-1920 | www.mghaspire.org

Last: First: DOB: Age: MGH MRN:

APPLICANT INFORMATION Preferred/Nickname:

EMERGENCY CONTACT INFORMATION

Is the applicant currently taking any prescription and/or nonprescription medication? Please list: Yes No

Are there any physical, mental or psychological conditions requiring medication, treatment, or restrictions while in programming? If yes, please explain:

Yes No

MEDICAL INFORMATION

What are the applicant's current interests and hobbies?

Is there any new information that you would like us to know about the applicant?

SUBMIT

ADDITIONAL INFORMATION

BILLING INFORMATION

Applicant:

Parent/Guardian:

Parent/Guardian:

Other:

First Last

Who? (e.g., District) Type

Other:

Chronic Health Conditions (e.g., asthma, diabetes, seizures)

Allergies Special Diet Does the applicant have any of the following? If yes, please explain:

Who is responsible for payment and billing (must select at least one)? If Other, family must submit a letter of commitment including amount and contact information.

List at least one contact in addition to a parent/guardian that could provide transportation home if necessary:

First: Last: Office: Cell: Ext: Type:Role:

Click Submit to open your default email client. Click Save to save file to your computer.

To email: please attach all required supporting documents (listed on the cover page) along with your completed application and send to mghaspire@partners.org. If you cannot email, please provide a printed copy via fax, mail, or in-person delivery to the address below.