Intake form

Help us serve you better

Name *

Email address *

What is your age?

What is your primary disability?

What programs are you interested in?

Please select at least one option.

Group Homes

Fitness Classes

Social Opportunities

High School Diploma Pathway

What is your preferred method of communication?

Do you have any specific health or fitness goals?

What days and times are you available for programs?

Do you require any special accommodations?

Additional questions or comments

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Specially Fit