Rensselaer ARC Enrollment Information Form

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" & "Services:
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" & (Request.Form("servicesCommunityInclusion")) & "" & vbCRLF & "" & (Request.Form("servicesSupportedEmployment")) & "
" & (Request.Form("servicesServiceCoordination")) & "" & vbCRLF & "" & (Request.Form("servicesRespite")) & "
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Form Completed by:
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Additional Comments: " & (Request.Form("additional_comments")) & "" ' Attachments none sm1.sendMail "one" Response.Redirect "thankyou.html" & "" end if SM_mailAction = getMailAction() %> Rensselaer ARC Enrollment Information Form Please fill out the following information and you will be contacted by a Rensselaer ARC Enrollment Specialist.

Name:
Date of Birth:
County of Residence:
Phone number:	(Best way to reach you between 8am-4pm)
Services:	(Please check all that apply)
	Planning Residential Services Group Day Hab/Individual Day Hab Community Inclusion Supported Employment Service Coordination Out of Home Respite Family Support Services (Recreation, Respite, Guardianship, Reimbursement) Transition Services
	Form Completed by: Parent Medicaid Service Coordinator Social Worker Other
Additional Comments: