Welcome to The Nextdecade Inc.
+ (805) 512-1843 drpattigault@aol.com
Monday-Friday 9:00am-3:00pm Sunday Closed
Providing Daily Support for Young Adultswith Disabilities Beyond School Age (22+)
(List needed skills mentioned by family for increased independence and participation in each area)
PLEASE COMPLETE BOTH SIDES IN BLUE OR BLACK INK (POR FAVOR COMPLETE AMBOS LADOS CON TINT A AZUL 0 NEGRA)
Student Ethnicity (Origen etnico. Marque uno)
Hispanic or LaUno (Una perscna de Cuban, Mexican, Puerto Rican, South or Central American, u otro origen o culture hispana sin importer Ia raza)
Not Hispanic or LaUno
Student Race (Raza del estudiante. Par favor marque haste 5 categories raciales). The above part of the quesUon is about ethnicity, not race. No matter what you selected above, please continue to answer the followinq by markinq one or more boxes to indicate what you consider your race to be.
American Indian or Alaskan Native I Indio Americana o Nafivo de Alaska (100) (Persons having origins in any of the original people of North, Central or Soutll America/ tener origen en cualquier pueblo originario de America del Norte, Central o del Sur )
Chinese / Chino (201)
Japanese / Japones (202)
Korean / Coreano (203)
Vietnamese / Vietnamita (204)
Asian Indian / Indio Asiatica (205)
Laotian / Lao (206)
Cambodian / Camboya (207)
Hmong (208)
Other Asian / Otro Asiatica (299)
Hawaiian (301)
Guamanian /Guaymeno (302)
Samoan (303)
Other Pacific Islander / Otras is/as del Pacifico (399)
Filipino/Filipino American (400)
African American or Black I Africano Americana o Negro (600)
White / Blanco (700) (Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East / Tener origen en cualquier pueblo originario de Europa, Africa del Norte o Medio Oriente)
Tahitian / Tahitiano (304)
1. Which language did the student learn when he first began to speak?(, Cual idioma aprendi6 su hijola primero?
2. What language does the student speak most frequently at home?(, Que idioma usa su hijola mas frecuente en casa?
3. What language is most spoken by the adults at home? t, Que idioma us an mas frecuente los adultos en cas a?
4. What language is most often spoken to the student by the parents? 1, Que idioma es usado mas frecuente por los padres con el estudiante?
In a single family permanent residence (house,apartment, condo, mobile home) / En una residencia permanente para una familia (casa, apartamento, condo,casa remo/que)
Doubled-up (sharing housing with other families/ individuals due to economic hardship or loss) / Multiplicada (compartiendo Ia vivienda con otras familiaslindividuos debido a dificultad o perdida econ6mica) ( 11)
In a shelter or transitional housing program / En un albergue o programa de vivienda transitoria (10)
In a foster home I En un hagar de crianza
Agency / Agencia:
In a motel/hotel (09)
Unsheltered (car/campsite) / A Ia intemperie (cochelcampamento) ( 12)
Licensed Child Institute 1/nstituto infantil certificado
Other (please specify) I Otro (especifique) (15)
I approve having photographs and video of my child taken for parents/guardians, school records and educational purposes. (Apruebo a que le tomen fotografias y video ami hijo/a para los padresltutores, expedientes escolares, y con fines educativos.) Yes/Si No
I approve having photographs and video of my child taken for use in news coverage, VCOE websites and social media platforms, and other informational materials for the public.(Apruebo a que le tomen fotografias y video a mi hijola para coberturas de noticias, sitios web de VCOE y plataformas de medias sociales, y otros materiales informativos parael p(Jblico.) Yes/Si No
Educational rights for this student are held by (estan a manos de):
As documented by I Como se document6 por:
Dated I Fechado:
I have reviewed this fonm for accuracy and all the information is correct I He revisado este formulario para exactitud y todo esta correcto.
I have made all necessary changes to this fonm (to ensure changes are noted, please use colored ink or highlight changes) I He hecho todos los cambios necesarios (para asegurar que los cambios se noten, favor de user tinta de otro color o resalte /os cambios).
Providing Daily Support for Young Adults with Disabilities Beyond School Age (22+)