Enrollment Form - https://roboenrichment.com/

Consumer First Name *

Consumer Middle Name *

Consumer Last Name *

Gender *

Age *

Phone Number *

Email Address *

Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Country *

Prefix

Referral First Name

Referral Middle Name

Referral Last Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Email Address

Agency/TitleAgency/Title

Does the Consumer know this application is being submitted on his/her behalf?

Engage in social recreation/social activities with others i.e. group exercise, interactions, follow instructions from teacher, coach, authority figure, parent, etc.Participation Ability

Mobility allows walking, brief running, bending, standing, sitting, stretching, moving arms/hands to engage with iRobotic dog, etc.Participation Ability

Self-help skill of minimal-to-moderate participation in basic recreation/social activity.Participation Ability

✓ Check potential areas of program benefit you would like to see the Consumer experience: *Alleviate poor social/recreation function i.e. sedentariness, low strength, poor engagement, low socializationImprove physical health i.e. functioning, fitness; community reintegration.Reduce health risk factors i.e. falls, decrease body weight, mobility, decrease blood pressure.Improve cognitive functioning i.e. attention span, alertness, problem solving, social skills.Reduce anxiety, stress, problem behaviors.

Please tell us how you learned about iRD-SIE:

Note the following iRD-SIE Program stipulations:

• iRD-SIE is not designed to serve those with a medical condition requiring continuous skilled nursing care, is rapidly

deteriorating; unable to move independently without assistance; mobility conditions prohibiting ambulation.

• iRD-SIE best meets the needs of Consumers who are mild-to-moderate emotionally/behaviorally challenged

with minimal inappropriate destructive or socially prohibitive behaviors; mild loss of control over/displays

of/to emoons/behaviors, mild inappropriate verbal responses. The program is not designed to serve frequent/

prolonged serious or self-abuse/violence resulting in injury, property damage, substance abuse, or running away.