APPLICATION FOR A BLISSFUL BEDROOMS MAKEOVER

Thank you for your interest in our organization. Only those who are young individuals (25 years and younger) with a severe disability, or multiple disabilities, will be considered for a bedroom makeover. Preference will be given to those individuals who live in New York City, depend on a wheelchair for primary mobility, currently have limited opportunities outside of their bedroom, and who have limited resources (i.e., they or their family/caregivers could not possibly provide this opportunity for them).

Please note, while we would like nothing more than to do a bedroom makeover for every person who submits an application (and qualifies), due to the large volume of applications received, as well as the substantial funding required for each makeover, it simply isn’t possible. All qualified applicants will be included in a pool of applicants. Each time we are prepared to identify the next candidate, we will randomly pick from that pool. We will get in touch if you meet the criteria and are picked for a bedroom makeover.

Please answer all of the questions as completely and accurately as possible. If a question does not apply to the Candidate, please mark N/A (not applicable)

1. Name of Bedroom Makeover Candidate:
2. Candidate's Date of Birth:
3. Name (and Relationship) of Person Filling Out Form:
4. Phone number:
5. Phone number:
6. Email Address:
7. Primary language spoken in the home:
8. Does the Candidate live at home with his/her family? NO YES
9. If no, please specify where the Candidate lives
   (i.e., Group Home, Nursing Home, etc.)
Parent/Caregiver Name(s) (relationship to child):___________________________________________________________
10. Does the Candidate live in a private house or apartment building? House Apartment
11. Does the Candidate live in government or subsidized housing? NO YES
12. Name of Housing Development (if this applies):

Address

13. Street Address:
14. Street Address 2:
15. City:
16. State:
17. Zip Code:
18. Length of time living at this residence:
19. Is the Candidate expected to relocate to a new residence in the next two years? NO YES
20. Does the Candidate have his/her own bedroom? NO YES
21. If no, who do they share the room with?
22. What are the approximate dimensions of the bedroom?
23. What family members live at home with the applicant (parents, siblings, relatives, etc.)?
    Please list names, relationship and age (of siblings).
    
    

    Name	Relationship	Age of Sibling

24. Average Household Income (check one): Below $20,000 $20,000-$35,000 $35,000-$50,000 $50,000+
25. Does the candidate receive government benefits (i.e., Social Security, Medicaid)? NO YES
26. Medical Diagnosis (check one):

    Cerebral Palsy Muscular Dystrophy Genetic Disorder Mental Retardation

    Down's Syndrome Traumatic Brain Injury Autism/PDD

    Spina Bifida Stroke Developmental Delay

    Other (please specify)
27. Past Surgeries (please specify date and type of surgery):
28. Allergies or Precautions (does the applicant have allergies/aversions to any materials or substances; alerts or precautions – i.e., seizures, etc.). Please describe:

Mobility

29. Can the candidate walk independently? NO YES
30. If yes, approximately how far can the Candidate walk before needing to rest?
31. If yes, does the applicant use any assistive devices? Crutches Walker Cane Other No device
32. Does the candidate use a wheelchair as a primary means of mobility? NO YES
33. Check one: Motorized wheelchair Manual wheelchair
34. Can the candidate propel his/her own wheelchair? NO YES
35. How old is the wheelchair and where was it obtained?
36. Does the Candidate use any orthotics/prosthetics? (please describe)
37. Does the Candidate have any adaptive equipment in the home (i.e., hospital bed, bath chair, grab bars, etc.)? Please specify.
38. Is there adaptive equipment that the Candidate is in need of? NO YES
39. Is the Candidate dependent for all activities of daily living? (i.e., transfers, eating, toileting, grooming, etc?) NO YES
40. If no, please describe the Candidate's level of independence and/or assistance the Candidate needs for activities of daily living:
41. Does the Candidate receive physical therapy or occupational therapy? NO YES
42. If yes, how often and where (i.e., home, clinic, school)
43. Does the Candidate do any regular exercise at home? NO YES
44. If yes, please describe:
45. Does the Candidate have a home attendant? NO YES
46. If yes, how many days/week and hours/day?
47. How does the home attendant assist the Candidate in his/her daily life?
48. Does the Candidate have functional voluntary movement of his/her upper and lower extremities? NO YES
49. Is the Candidate able to use his hands and fingers functionally? (i.e. press buttons on remote control, use a keyboard/mouse, turn on switches, use game joy stick, etc.) Please describe:
50. Does the Candidate have experience with using a computer? NO YES
51. Does the Candidate have an email account? If yes, what is his/her email address?
52. Does the Candidate have Facebook? NO YES

School

53. Does the applicant currently attend a New York City District 75 public school? If yes, which school?
54. Did the Candidate graduate from a New York City District 75 public school? If yes, what year?
55. Does the Candidate attend another school? If yes, where?
56. Does the Candidate attend an After School Program? NO YES
57. If yes, which program does the Candidate attend?
58. If yes, which program does the Candidate attend?
59. If the Candidate does not attend school, does he/she attend an Adult Day Program? NO YES
60. If no, is the applicant being considered for a program or is he/she on a waiting list to be placed in a program? NO YES
61. If yes, which program does the Candidate attend?
62. What types of activities/services are included in the program?
63. How many days a week?
64. Hours of Program
65. Does the Candidate participate in any recreational activities outside of the home? NO YES
66. If yes, please describe
67. How often and length of duration?
68. How does the Candidate get to these events?
69. Does the Candidate have friends outside of the family, with similar physical challenges, that he/she socializes with on a regular basis? NO YES
70. Would the Parents/Caregiver be open to the Candidate participating in Blissful Bedrooms social events throughout the year? NO YES
71. Does the Candidate have access to transportation in order to get to these events? (Do you have an accessible vehicle or a reliable source of transportation, Access-A-Ride, etc. – please specify) NO YES

Candidate's interests

72. Please describe the Candidate's interests (i.e., how he/she spends time at home, hobbies, favorite TV shows/movies, favorite music, favorite characters/heroes, favorite toys, activities/things/objects that makes the applicant happy, etc.). Please be as detailed and specific as possible:
73. What is the Candidate's favorite color(s)?
74. Does the Candidate have a special dream?
75. What do you think the Candidate may like as a theme for his/her Blissful Bedroom makeover?
76. Is there anything else you can tell us about the Candidate in order for us to have a better understanding of what makes him/her happy?
77. Why do you believe the Candidate would benefit from a Blissful Bedrooms makeover and how do you think this will change his/her life?

Many, many people contribute funds, materials and volunteer their time and skills in order to make Blissful Bedrooms makeovers possible.
Although this is our gift to the Candidate and you are not expected to contribute financially, we do ask that that the Candidate and his/her family/caregivers make a sincere promise to our team to take good care of the bedroom and do your/their best to keep it looking as beautiful, clean and organized as the day it was created.

78. Can the Candidate and/or his/her family members and caregivers make this commitment? NO YES
79. By checking the box below, you attest that all the above information is true to the best of my knowledge I attest that all the above information is true to the best of my knowledge