Name: Getting the Necessary Coverage | Understand the Medicare Loophole
Start: 2018-10-11T18:00:00-04:00
End: 2018-10-11T19:30:00-04:00
Location: Mission Empower

Information Release and Signature (To Be Completed by Parent/Guardian)
If you are 18 or older, please complete the following information with your name in the Youth and Parent/Guardian fields.
Youth's Name*
First Last
Today's Date*
I hereby grant permission for Mission Empower to make contact with my child and conduct a personal interview for the purposes of applying to be in the Youth Envision Program.

We encourage parents to attend the interview with their child. Please provide a time & day of the week that works best for you.
Example: M/W/F 3-4pm*
I understand that basic information about my child will be kept private in accordance with HIPPA privacy laws. By signing below, I verify all information listed on this application is accurate.
Parent/Guardian Signature*
Today's Date*
We look forward to contacting you to set up an interview with you!

Please be aware that submitting this application does NOT guarantee you a spot at the Summer Youth Summit. ALL applicants will be interviewed, screened, and given final consideration regarding their eligibility to join the program by the Youth Envision program coordinator(s) and Mission Empower's executive director. We thank all applicants for their interest in the program.

Youth ENVISION - Youth Application

Step 1 of 3

Student Demographic Information

Parent/Guardian Information

Emergency Contact Information

Application Questions (To Be Completed By Youth)

By signing below, I verify all information listed on this application is accurate, and that I will commit to my participation in the Youth Envision Program.

Information Release and Signature (To Be Completed by Parent/Guardian)

I understand that basic information about my child will be kept private in accordance with HIPPA privacy laws. By signing below, I verify all information listed on this application is accurate.

We look forward to contacting you to set up an interview with you!

Youth ENVISION Summer Summit

Navigating the World of Transition

Combined IEP Part 1 & 2 Training

Getting the Necessary Coverage | Understand the Medicare Loophole