ASSIST/Sibling Referral

ASSIST is a group facilitated by a Special Education Teacher designed for children aged 5-10, who are residents of Orange County and have OPWDD eligibility.

Not using OPWDD services?

If your child does not have OPWDD eligibility or a sibling with that eligibility, but your child still needs
social skills support, complete the form to register or learn more about our

Friends Program
.

Go to Friends Program form

#1 Parent Name #1 Parent Name First Last
#2 Parent Name #2 Parent Name First Last
Child Name Child Name First Last
Age
Phone Phone - ### - ### ####
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Preferred Contact Method

Preferred Contact Method Text Email Phone Call
Has OPWDD Certification

Has OPWDD Certification Yes No
What Should we Know About Your Child?
Has a Sibling?

Has a Sibling? Yes No
MHAOC has a fun, welcoming program for siblings
(ages 5-21) of children with disabilities - SUPER SIBLINGS

.
Would you like to sign up your other child/children for Super Siblings at this time?

Would you like to sign up your other child/children for Super Siblings at this time? Yes No
How many siblings would you like to register?
Sibling #1 Name Sibling #1 Name First Last
Sibling #1 Age
Sibling #2 Name Sibling #2 Name First Last
Sibling #2 Age
Sibling #3 Name Sibling #3 Name First Last
Sibling #3 Age
Sibling #4 Name Sibling #4 Name First Last
Sibling #4 Age
Sibling #5 Name Sibling #5 Name First Last
Sibling #5 Age
Sibling #6 Name Sibling #6 Name First Last
Sibling #6 Age
What should we know about the siblings that you are registering? (ex. personality, likes, dislikes, challenges)

ASSIST/Sibling Referral

ASSIST/Sibling Referral

MHAOC has a fun, welcoming program for siblings (ages 5-21) of children with disabilities - SUPER SIBLINGS

MHAOC has a fun, welcoming program for siblings
(ages 5-21) of children with disabilities - SUPER SIBLINGS