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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

CAPTCHA

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First Choice

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Third Choice

Social

Hours of Operation

Monday - Friday, 8am - 6pm

Contact

469-241-9100

mponline@mptx.org

© 2020 My Possibilities

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