Application - The Social Cog

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Membership Application

Name and Address
1
Supporter Information
2
Emergency Contact
3
Work & Education
4
Personal Information
5

Name and Address

All information is kept completely confidential. Someone will contact you soon after you submit your application.

All fields marked with are required.

First Name

Last Name

Date of Birth

Street Address

City

State

Zip

Applicant Email

Applicant Cell Phone

Applicant Home Phone

Relationship Status

Who do you live with?

What is your primary mode of transportation?

Supporter Information

Please enter the required information about your supporter

All fields marked with are required.

What is the name of your primary supporter (parent, guardian, etc.)?

Supporter's Email

Supporter's (parent, guardian, etc.) Cell Phone

What is the best phone to reach you?

Do you have a guardian appointed by court order pursuant to Chapter 744, Florida Statues?

If you answer yes, we will need a copy of your court order. Please bring it to Orientation.

Yes No

Emergency Contact

Please enter information related to your emergency contact

All fields marked with are required.

Person to contact in case of emergency

Emergency Contact's relationship to applicant

Emergency Contact phone number

Work & Education

If you answer yes to either question please provide details

Are you currently a student?

Where are you a student?

What are you studying?

Are you currently employed?

Where are you employed?

Occupation

How long have you been there?

Personal Information

All fields marked with are required.

Please list some of your interests

Please describe some of your strengths

Please describe some of your limitations

Please list any chronic illnesses or medical conditions

Please list any medications you currently take

If you have ever received psychotherapy or counseling, please tell us when

approximately and with whom

If you have ever received treatment from a psychiatrist or been prescribed psychotropic medication, please tell us who and what medications

If you have ever been hospitalized for mental health reasons, please tell us when and for what reason

Have you ever been treated for alcohol or substance abuse?

How did you hear about The Social Cog?

Thank you for taking the time to fill out our application! Is there anything else that you feel we did not ask about that will help us get to know you better?

We want to thank all of you, our donors and supporters for believing in us and helping us achive our goals!

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The Social Cog, Inc
2925 Aventura Blvd, Suite 300
Aventura, FL 33180
p 305 501-2333
sdamelio@thesocialcog.org

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Membership Application

Membership Application

Name and Address

All information is kept completely confidential. Someone will contact you soon after you submit your application.

Supporter Information

Please enter the required information about your supporter

Emergency Contact

Please enter information related to your emergency contact

Work & Education

If you answer yes to either question please provide details

Personal Information

We want to thank all of you, our donors and supporters for believing in us and helping us achive our goals!

Stay up-to-date with our latest news: register your email now!

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