Language
English (US)
Español
Start Your Journey with Legacy!
We're excited that you're interested in becoming part of the Legacy Empowerment Services community. Please take a few moments to complete this Member Interest Form. Your responses will help us learn more about you, your goals, and the supports you're looking for so we can connect you with the services that best fit your needs. Once your form has been submitted, a member of our team will review your information and reach out to discuss the next steps. We look forward to getting to know you and helping you begin your journey with Legacy!
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your preferred way to hear from Legacy?
*
Phone
Email
Who is filling out this survey?
*
Member/Self
Family Member
Support Coordinator/Case Manager
School
Healthcare Provider
Legacy Service Coordinators
Other
Member's Name
*
If you are a Support Coordinator/Case Manager, which agency are you affiliated with?
*
Are you currently enrolled with the Division of Developmental Disabilities (DDD)?
Yes
No
Unsure
If yes, do you currently have a Support Coordinator/Case Manager?
Yes
No
Not Applicable
Please provide the Support Coordinator/Case Manager’s email address:
Which services are you interested in? (Select all that apply)
*
Academic tutoring
Author Development
Community Inclusion
Companion Services (CBS)
Culinary Instruction
Driver's Education
Housing Supports
Life Skills
Music Exploration and Production
Supported Employment
Transportation
Other
Do you have any dietary restrictions or food allergies? If so, please list
How comfortable are you with their current cooking skills?
*
No experience
1
2
3
4
5
6
7
8
9
Master Chef
10
1 is No experience, 10 is Master Chef
What recipes would you be interested in cooking?
Which location would they like to attend classes at?
Please Select
Garfield Senior Center
Little Fox Kitchens in Cranford
Emergency Contact's Name & Phone Number
*
Are you stably housed?
*
Yes
No
Unsure
MCO Name
Please write a short description of your current situation and goals.
Please share any additional information, needs, or questions.
Upload supporting documents (ISP, PCPT, IEP, or other relevant paperwork): Optional at this time. If you do not have these documents available right now, you may skip this step; however, please note that all supporting documentation will ultimately be required at a later date before completion.
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Interest
Should be Empty: