Independence Prep Application

We’re excited to learn more about you!

To complete the next step in enrolling for Independence Prep, please complete the below application and submit your $50 non-refundable deposit.

Once we have received your application and deposit, we’ll contact you to begin the next step in the process: a personal interview.

If you have any questions as you complete the application, please email Executive Director Jennifer Roccanti at jennifer@onmyownofmi.org.

Independence Prep Application

Step 1 of 3

Student First + Last Name*
Student Date of Birth*
Student Gender Identity*
Student Grade Level*
Student School Name:*
Student Developmental Disability*
Do you currently have an IEP, 504 plan or annual plan of service?*
- Yes
- No

Student Address (please include street, city, state + zip code)*
Student Email Address
Student Cell Phone Number
Parent / Guardian #1 First + Last Name*
Parent / Guardian #1 Relationship to Student*
Parent / Guardian #1 Address (please include street, city, state + zip code)*
Parent / Guardian #1 Email Address
Parent / Guardian #1 Cell Phone Number*
Parent / Guardian #2 First + Last Name
Parent / Guardian #2 Relationship to Student
Parent / Guardian #2 Address (please include street, city, state + zip code)
Parent / Guardian #2 Email Address
Parent / Guardian #2 Cell Phone Number
Most Recent Teacher or Social Worker First + Last Name (to provide recommendation)*
Teacher or Social Worker Relationship to Student
Teacher or Social Worker Email Address*
Teacher or Social Worker Phone Number*

Student Allergies
If I get anxious during my weekend away, please do the following to help me:
To help me have a great experience, you should also know this about me:
I heard about Independence Prep from:

Make $50 Deposit