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MPower Online Learning - External Application
This is the application to submit your interest in MPower Online Learning services. Upon completion of this application, you will be contacted to set up a Zoom interview before enrollment is completed.
MPower Online Learning services does not accept waiver-based funds, all enrollment fees are self-pay only at this time. Are you still interested in these services?
(Required)
Yes
No
Applying or enrolling in MPower Online Learning services has no bearing on admission, acceptance or access to any other My Possibilities programs. By submitting this application, you are acknowledging that participation in MPower Online Learning WILL NOT impact any current status held with My Possibilities.
(Required)
Yes
No
Applicant Name
(Required)
First
Last
Applicant Date of Birth
(Required)
MM slash DD slash YYYY
Where does the applicant live? Where will the applicant attend classes?
(Required)
Applicant's Parent/Guardian's Name
(Required)
First
Last
Applicant's Parent/Guardian's Phone Number
(Required)
Parent/Guardian Email Address
(Required)
Enter Email
Confirm Email
Is the above person the applicant's parent or guardian? Check all that apply.
Parent
Guardian
Parent/Guardian Contact #1 Information - Name
(Required)
First
Last
Parent/Guardian Contact #1 Information - Phone Number
(Required)
Parent/Guardian Contact #1 Information - Email Address
(Required)
Enter Email
Confirm Email
Parent/Guardian Contact #1 Relationship to Applicant
(Required)
Parent/Guardian Contact #2 Information - Name
First
Last
Parent/Guardian Contact #2 Information - Phone Number
Parent/Guardian Contact #2 Information - Email Address
Enter Email
Confirm Email
Parent/Guardian Contact #2 Relationship to Applicant
Medical Information/Diagnosis
(Required)
Does the applicant have a history of seizures?
(Required)
Yes
Now
What is the applicant's history with seizures? Are the seizures grand mal, non-grand mal, absence? How often do they occur?
(Required)
Emergency Contact During Class Time
(Required)
First
Last
Emergency Contact Phone Number
(Required)
Emergency Contact's Relationship to Applicant
(Required)
Additional Comments
What are the appplicant's goals?
(Required)
What is important for the applicant?
(Required)
What things are important to the applicant?
(Required)
Is applicant able to independently use a computer/Zoom? (This does not determine access to MPOL)
(Required)
Yes
No
With assistance
Other
How did you hear about MPower Online Learning?
(Required)
via My Possibilities admissions process
Interested in My Possibilities Day Programming (in application process, toured previously, etc)
Other ongoing MP services (Therapy, Personal Training, Career Services)
Provider or Group Home
Alternate Adult Day Program
Other
Other information
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