PUBLIC HEALTH and SOCIAL SERVICES DEPARTMENT        Schelli Slaughter - Director
COUNTY  COMMISSIONERS                                                                                                                                                                                  Dr. Dimyana Abdelmalek - Health Officer 
Carolina Mejia District One                                                                                                                                                                                                                    
Gary Edwards  District Two
Tye Menser     District Three


Gender : *
Participant Lives With: *
Are you using DDA Funds to pay for programs? *
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 registration form. *
Check all that apply:
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. *
Communication (check all that apply): *
Toileting (check all that apply): *
Allergies (check all that apply): *
I use:
Mobility (check all that apply): *
Dietary (check all that apply): *
Do you have a history of wandering? *
Check all that apply: *
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.
Please choose one: *
Signature: *
412 Lilly Rd. N.E., Olympia, Washington 98506-5132
(360) 867-2588  FAX (360) 867-2600  TDD (360) 867-2603 TDD (800) 658-6384