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Home > Services > Recreation > Recreation Application

Recreation Application

Please complete the following application for AIM’s Recreation program.

Before you begin, please be sure to have the following information ready:

Emergency contact information
Medicaid number
Other Insurance information (if applicable)
Diagnosis, allergies and medications
Care Manager contact information
Self Direction Support Broker and Fiscal Intermediary contact information (if applicable)
Participants interests and fears
Participants medical or dietary precautions, and adaptive equipment needs (including for transportation)

Please contact your Care Manager and have them submit the following paperwork to CBidwell@aimservicesinc.org:

2 most current Life Plans
Service Authorization (NOD.9)
HCBS Waiver (NOD.1)
OPWDD Determination of Eligibility
Current Level of Care Eligibility of Determination (LCED)
Consent/Authorization Forms Signed or Declined

Please note, once your application and paperwork is received, the participant will begin Recreation on a trial basis.

If you have any questions, please contact Caryn Bidwell at CBidwell@aimservicesinc.org

AIM Waiver Respite & Recreation Programs

Teen/Adult Recreation Teens ages 12-18 Adults ages 18+

Monday & Wednesday Music Therapy: This program is facilitated by Expressive Journeys and is designed for anyone that has a love for music. A variety of instruments are provided to try out! This program requires transportation to and from the AIM Office.

Saturday Recreation: This program is designed for active teens and adults who would like to participate in a variety of recreational activities in the area. Previous activities have included snow-tubing, festivals, sporting events, movies, theatres, hiking, boat/train rides, and more! The program offers a variety of experiences, at little to no cost. This program requires transportation to and from the AIM Office or STRIVE Site.

Children’s Recreation ages 5-12

School Breaks Free Play (School-Aged): This program provides daytime respite care for school aged participants during school breaks. We provide scheduled activities to keep your child engaged during break. Snacks will be provided, please pack a lunch. We follow the Saratoga School district for breaks. Transportation to and from our STRIVE Site is required.

AIM Recreation Application

"*" indicates required fields

Facebook

This field is for validation purposes and should be left unchanged.

Demographic Information

Participant's Name*

First Last

Participant's Phone

Phone Type

Home

Cell

Address*

Street Address City State ZIP Code

Do you have another address you'd like to list?

Yes

No

Alternate Address

Street Address City State ZIP Code

Parent/Guardian's Name*

First Last

Email*

Work Phone

Cell Phone

Please select which number is best to reach out in an emergency.*

Work Phone

Cell Phone

Alternative Emergency Contact's Name*

Not a parent/guardian.

First Last

Relation to Participant*

Emergency Contact's Phone*

Medical

Date of Birth*

Month

Day

Year

Medicaid Number*

Other Insurance (if applicable)

Policy Holder

ID # / Group #

Diagnosis

Allergies

If none, leave blank.

Medications

If none, leave blank.

Can the participant self-medicate?*

Yes

No

Does the participant have a seizure disorder?*

Yes

No

Behavioral concerns

If none, leave blank.

Aggressive/Abusive (verbally or physically) concerns

If none, leave blank.

OPWDD Support Services

Care Manager Agency*

Care Manager's Name*

First Last

Care Manager's Phone*

Care Manager's Email*

Do you utilize Self Direction?*

Yes

No

Support Broker's Name

First Last

Support Broker's Phone

Support Broker's Email

Fiscal Intermediary Agency

Fiscal Intermediary (FI)'s Name

First Last

FI's Phone

FI's Email

Please list all other OPWDD Services you utilize

If none, leave blank.

Recreation Program Specifics

Please check all interested Recreation programs*

Teen/Adult Monday Music Therapy

Teen/Adult Wednesday Music Therapy

Teen/Adult Saturday Recreation

Children's School Breaks Free Play Recreation

Are you willing to transport to an activity or a designated drop off/pick up site?*

Please note, transportation will be necessary for most programs.

Yes

No

Is the participant comfortable with long car rides?*

Yes

No

Is the participant known to wander?*

Yes

No

Participant's Likes / Interests*

Participant's Fears

If none, leave blank.

Medical or Dietary Precautions

If none, leave blank.

Can the participant utilize the restroom independently?*

Yes

No

Can the participant dine independently?*

Yes

No

Can the participant ambulate independently?*

Yes

No

Adaptive Equipment/Supports Needed

If none, leave blank.

Media Consent

We publicize our programs on our website and social media, and throughout the year at trainings and conferences. Participants are always shown in a positive and uplifting way. We never share last names or personal contact information of the participant. Please read the consent below, and check the box if you agree to allow us to share pictures and videos.

Media Consent

I agree to the media consent and give permission for AIM to share pictures/videos.

I hereby give consent to AIM Services, Inc. (Hereinafter AIM) to take and use photographs/videos. I understand that the intended purpose and use of such images and information is for advertising, marketing, fundraising or promotional purposes of AIM. I hereby waive the right to confidentiality of the information disclosed to the public as contemplated in the release.
I acknowledge that this consent is being made solely for the benefit of AIM and without any expectation of compensation or other benefit to me. To the extent that any benefit accrues or might accrue to AIM from the use of images or disclosure of information, I hereby and forever waive any interest in or claim to such benefits.
I hereby release and forever discharge AIM and its affiliates, officers, directors, trustees, clinical staff, employees and agents from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to or in any way connected with the use of photographs/videos described herein, and I hereby waive all rights and interest in and to such materials.

Sunscreen and Bug Spray Consent

AIM Services Recreation programs participate in many outdoor activities. We encourage families/ individuals to apply sunscreen and or bug spray prior to participation in our recreation programs. Should additional applications be deemed necessary, AIM staff will have sunscreen and bug spray on hand. Please sign below if you give consent for AIM Services staff to reapply sunscreen and bug spray as needed.

Sunscreen and Bug Spray Consent

Please check the boxes if you give permission. If you do not, please leave blank.

I give permission for AIM Services Staff to apply sunscreen as needed.

I give permission for AIM Service Staff to apply bug spray as needed.

If the participant is allergic, please list the brand/type of sunscreen/bug spray that can be used.

Please note, you will need to provide these particular sunscreens/bug sprays.

Medical Treatment Authorization

Medical Treatment Authorization

I hereby give consent for AIM Services staff to obtain treatment in case of an emergency.

Please describe the medical treatment you are authorizing.

Signature

Signature

I certify that all the information outlined above is accurate to the best of my knowledge. If any of the information stated changes, I will alert AIM Services Inc. immediately. If the participant utilizes Self-Direction, I will work with the Self Direction Team to assure all necessary paperwork is updated and submitted in a timely manner. If accurate records are not maintained, I may be held liable for the cost of the supports.

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