Participant's Full Name
Have you attended our Ezra Class in person, Wednesday at Noon Before?
Yes
No
Phone
Email
Participant will be accompanied?
only by themselves.
by Family Member
Staff, DSP, Etc.
Name of person Accompanying Participant
Do You Use Self Direction
Yes, already
Soon will be
No
Which Self Direction Agency
(Required)
Rayim
AIM Services, Inc.
Halo Network, Amityville
Halo Network, Shirley
DDI Developmental Disabilities Institute
EOC of Suffolk
A1 Universal Care
Meaningful NY Suffolk
Meaningful Brooklyn
East End Disability Associates EEDA
The Resource Center of Independent Living (RCIL)
ACDS
Community Mainstreaming Associates
ISS
Other
Hidden
Which session do you plan to attend
11/10 Mama Mia Bowtie Pasta With Homemade Marinara & Ricotta
11/17 French Toast & Fruit Kebabs
11/24 Thanksgiving – Homemade Stovetop Stuffing & Orange Cranberry Sauce
Other
Not sure
They are each Wednesday at Noon.
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