MARYLAND TRUST FOR RETARDED CITIZENS, INC. 180 Kriders Church Rd., Westminster, MD 21158 Baltimore Line: (410) 876-1836 FAX: (410) 876-4185 Toll Free: 1-800-323-9407 mtrc@ix.netcom.com MTRC APPLICATION CLIENT INFORMATION DATE _/ _/ CLIENT'S NAME: ___________________________________________ DATE OF BIRTH: _/_/ First M.L Last ADDRESS: _______________________________________________________________________________ Street City State Zip COUNTY: __________________ TELEPHONE: _______________ SOC. SEC. #: _________________ SEX: _______ COURT APPOINTED GUARDIAN (If any): _______________________________________ FULL SCALE I.Q. *: __________ PRESENT DAY PROGRAM: ___________________________________ * (Psychological Evaluation must accompany this application) ---------------------------------------------------------------------------------------- FATHER'S NAME: _______________________________________________ DATE OF BIRTH: _/_/ First M.L Last ADDRESS:________________________________________________________________________________ Street City State Zip TELEPHONE: ___________________________ PRESENT STATE OF HEALTH: ______________________ COMMENTS: ______________________________________________________________________________ ---------------------------------------------------------------------------------------- MOTHER’S NAME: _______________________________________________ DATE OF BIRTH: _/_/ First M.L Last ADDRESS: _______________________________________________________________________________ Street City State Zip TELEPHONE: ___________________________ PRESENT STATE OF HEALTH: ______________________ COMMENTS: ______________________________________________________________________________ ---------------------------------------------------------------------------------------- SPONSOR(S)(If not parents): ___________________________________ DATE OF BIRTH: _/_/ First M.L Last ADDRESS: _______________________________________________________________________________ Street City State Zip TELEPHONE: ___________________________ PRESENT STATE OF HEALTH: ______________________ RELATIONSHIP TO CLIENT: ____________________ COMMENTS: ________________________________ The eligibility criteria to receive MTRC services is: (1) a diagnosis of mental retardation with or without other disabilities, (2) the State of Maryland as the primary service area (each application is considered on an individual basis), and (3) A PSYCHOLOGICAL EVALUATION COMPLETED WITHIN 3 YEARS OF THE DATE OF APPLICATION (MUST ACCOMPANY THIS APPLICATION). The current sponsorship fee ($2,000.00) will be completed within two years subsequent to notification to sponsor(s) of applicant's approval by Board of Directors. No services will be initiated until the full sponsorship fee has been received. All payments are intended to be nonrefundable. However, during the payment period, if application is withdrawn, the fees paid to date will be refunded minus an administration fee of $250.00. Parent(s) or other Sponsor(s) Signature(s):_________________________________________________________________