PHSS Special Recreation Participant Profile

SPECIALIZED RECREATION PARTICIPANT PROFILE

Participant First Name *

Participant Last Name *

Address *

City *

State *

Zip Code *

Phone Number *

Alternate Phone Number

Primary Email Address *

Secondary Email Address

Age: *

Date of Birth: * +

Gender : *

Participant Lives With: *

Name of Parent/Guardian/Family Member/AFH/Support Living Agency: *

Phone:

Are you using DDA Funds to pay for programs? *

Yes

No

If yes, enter case worker name: *

Will an attendant/staff/care provider/guest be attending programs with the participant? *Participants who require one on one assistance with toileting, feeding, transfers, medication distribution, and/or behavior management are required to bring an attendant. All attendants must register using a separate participant registration form. *

Yes

No

Emergency Contact Name: *

Emergency Contact Phone Number *

Emergency Contact Alternative Phone Number

Relationship: *

Emergency Contact Name: *

Emergency Contact Phone Number *

Emergency Contact Alternative Phone Number

Relationship: *

Primary Disability: *

Secondary Disability:

Physician Name: *

Physician Phone Number: *

Insurance Company:

Insurance Policy Number:

Check all that apply:

I have a history of seizures

I have seizures that typically last more than 3 minutes

I have been hospitalized due to seizures

I have history of diabetes

I control diabetes by insulin

If you answered yes to seizures, describe what recovery is like:

If you answered yes to diabetes, are there any additional comments you would like to add in reference to your diabetes:

Are you currently taking medication? *If medications are required during programs, you or an attendant must administer medication. Staff are not responsible for holding, dispensing, or monitoring medication. *

Yes at home

Yes at school

Yes during program time (*see note above )

No I do not take medication

Communication (check all that apply): *

Comments about communication:

Toileting (check all that apply): *

Comments about toileting:

Allergies (check all that apply): *

I use:

EpiPen

Inhaler

If you checked any allergies above what specifically are you allergic to (i.e. peanuts):

If you checked any allergies above what should be done in the event of a reaction:

Mobility (check all that apply): *

Dietary (check all that apply): *

Please describe any dietary needs:

Please describe any disliked foods

Please describe any disliked foods:

Are there any foods you must avoid or be controlled for? If yes, please explain:

How can we encourage positive behaviors?

How can we prevent and discourage problem behaviors?

What types of noises or situations bother you?

What are your reactions to the situation?

Do you have a history of wandering? *

Yes

No

If yes, what are the triggers?

What do you like to do for fun?

Do you have a job? If Yes, where do you work?

Who should we contact with questions/concerns and what is their relationship to you?

Check all that apply: *

I am aware of the late fee policy

I am aware of the outstanding balance repayment expectation

I am aware of the refund and cancellation policy

How did you hear about us?

Participant will be arriving to programs via (check all that apply): *As a reminder, staff are only onsite to supervise participants 15 minutes prior and 15 minutes after programs.

If you answered "other" above please explain:

Is there any other helpful information staff should know?

Please choose one: *

I am authorized to sign my own legal documents.

The person named above is under 18 years of age I am the parent who is authorized to sign legal documents.

I am the legal guardian authorized to sign legal documents for the person I named above.

Printed Name of Signee: *

Date: * +

Signature: *

clear

Mild Food Allergy	Severe Food Allergy
Severe Asthma	Mild Asthma
Mild Insect	Severe Insect
Mild Medication	Severe Medication
No Allergies

Independent	Walker
Walks With Support	Cane
Balance Issues	Restricted to under ½ mile
Power Wheelchair	Manual Wheelchair
Independent Wheelchair	Dependent Wheelchair

No issues	Full assistance needed cutting/serving food
Some assistance needed cutting/serving food	Difficulty swallowing
Lactose Free	Gluten Free
Kosher	Vegan
Vegetarian	Low Sodium
Not okay to have fast food