Ignite Adulthood Application

Legal Name(Required)

First Last

Preferred Names (If Different From Above)

Preferred Name(s)

Date of Birth(Required)

Gender(Required)

Preferred Pronouns

Weight(Required)

Height(Required)

Are You Currently Enrolled in School?(Required)

Yes

Are You Currently Employed?(Required)

Yes

Do You Have Any Religious Preferences?

Yes

If Yes, Please Describe

Contact Information

Applicant Email Address(Required)

Applicant Phone Number(Required)

Applicant's Primary Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Contact Information

Name(Required)

First Last

Relationship to Applicant

Phone Number(Required)

Email Address(Required)

Address

Street Address Address Line 2 City State ZIP Code

Employer

Work Email

Work Phone

Secondary Parent/Guardian Contact Information

Name

First Last

Relationship to Applicant

Phone Number

Email Address

Address

Street Address Address Line 2 City State ZIP Code

Employer

Work Email

Work Phone

Education History

Name of Current School (If Applicable)

Highest Level of Education Completed

What areas of your education have been the most challenging for you?

What areas of your education have been the most interesting?

Medical History

Do You Have Any Allergies or Asthma?(Required)

Yes

If yes, please describe

Do you require an epinephrine pen or inhaler?

Yes

Have you been hospitalized for Asthma or Allergies in the past?

Yes

If yes, please describe

Do You Have Dietary Restrictions?(Required)

Yes

If yes, please describe

Please describe any past surgeries, serious medical conditions, or hospital admissions:

Provide a list of any medications you take (both prescription and non-prescription), along with the dosage, purpose, and the prescribing doctor’s phone number:

If applicable, please describe any side effects of current medications:

Do you manage your medications correctly and consistently without needing support?

Yes

Please describe any medical or physical conditions that may limit your ability to participate in physical activity:

Date of Last Physical Exam:

Please provide the dates of your vaccinations for the following diseases:

Hepatitis B:

Polio:

Measles, Mumps, Rubella:

Tetanus/Diphtheria:

Flu:

Covid-19

Mental Health History

Have you ever received a mental health diagnosis from a licensed professional?(Required)

Yes

If yes, please list the conditions below:

Do you currently or have you in the past experienced symptoms such as anxiety, depression, or mood instability?(Required)

Yes

If yes, please describe:

Do you struggle with obsessions (unwanted thoughts) or compulsions (repeated behaviors) that interfere with daily life?(Required)

Yes

If yes, please describe:

Have you ever had any involvement in lying, theft, vandalism, drug dealing, or other unlawful behaviors?(Required)

Yes

If yes, please describe the incidents and include dates:

Have you ever been involved in the legal system (charges, convictions, probation, felonies, misdemeanors)?(Required)

Yes

If yes, please describe your legal record (charges, convictions, probation, misdemeanors, felonies) and your current legal situation.

Do you experience any issues related to alcohol, drug use, or dependency(Required)

Yes

If applicable, provide details about your substance use history, including age of first use, substances used, frequency/patterns of use, method of use, and cigarette/nicotine use.

Do you struggle with other potentially addictive patterns, including gaming, TV, phone, internet, sex, or gambling?(Required)

Yes

If yes, please describe:

Do you tend to withdraw or avoid social interaction?(Required)

Yes

If yes, please describe:

Do you find it hard to begin your day or participate in regular routines?(Required)

Yes

If yes, please describe:

Have you had situations where disagreements escalated into physical altercations?(Required)

Yes

If yes, please describe the incident(s) in detail:

In what ways do you usually respond when you feel angry?

Please describe any significant life events you have experienced (such as divorce, relocation, birth of a sibling, loss, death, abuse, illness, etc.). Include the date of each event.

Please describe any sexual behaviors that might be considered unsafe, unhealthy, or concerning (e.g., unprotected sex, coercive behavior).

Have you ever experienced thoughts of harming yourself or suicide, or made an attempt?(Required)

Yes

If yes, please describe what happened and when:

Nutrition Preferences

Do you have any food intolerances?(Required)

Yes

If yes, please list them below:

Are there particular foods you strongly dislike?

Please describe any unusual eating patterns or behaviors?

Program Information

How did you first learn about Ignite Adulthood?

What specific events or circumstances led to your decision to seek additional support?

Are there certain changes or improvements you hope to make while at Ignite Adulthood?

What do you see as your personal strengths? (This could be in areas like creativity, academics, relationships, or physical ability.)

What areas do you identify as needing growth or improvement? (This could be in areas like creativity, academics, relationships, or physical ability.)

Please describe your involvement in outdoor recreation and physical activities?