subject_line
PUBLIC HEALTH and SOCIAL SERVICES
SPECIALIZED RECREATION PARTICIPANT PROFILE
Participant First Name
*
Participant Last Name
*
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Alternate Phone Number
Primary Email Address
*
Secondary Email Address
Age:
*
Date of Birth:
*
+
Gender :
*
Male
Female
Non-binary
Prefer to self describe
Prefer not to answer
Participant Lives With:
*
Self
Roommates (Supported Living)
Adult Family Home
Parent/Guardian
Other family member (s)
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):
*
Verbal
Uses Sign Language
Verbal, but hard to understand
Blind
Non Verbal
Deaf
Comments about communication:
Toileting (check all that apply):
*
No issues
Needs prompting
Needs standby supervision
Wears adult diapers
Incontinent
Comments about toileting:
Allergies (check all that apply):
*
Mild Food Allergy
Severe Food Allergy
Severe Asthma
Mild Asthma
Mild Insect
Severe Insect
Mild Medication
Severe Medication
No Allergies
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):
*
Independent
Walker
Walks With Support
Cane
Balance Issues
Restricted to under ½ mile
Power Wheelchair
Manual Wheelchair
Independent Wheelchair
Dependent Wheelchair
Dietary (check all that apply):
*
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
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?
Current Participant
Friend
Employer
Caseworker
Other
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.
Walking/driving self to programs
Family/friend drop off
Dial A Lift
Intercity Transit bus
Other
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
412 Lilly Rd. N.E., Olympia, Washington 98506-5132
(360) 867-2679 FAX (833) 499-1806 TDD (360) 867-2603 TDD (800) 658-6384
www.thurstoncountywa.gov/phss