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EMERGENCY CONTACT INFORMATION CONTINUED
# 3: ____________________________________________________________________________________________________________
First and Last Name Phone Number( Home Work Cell, please select for # listed)
____________________________________________________________________________________________________________
City
Relationship to Participant
# 4: ____________________________________________________________________________________________________________
First and Last Name Phone Number( Home Work Cell, please select for # listed)
____________________________________________________________________________________________________________
City Relationship to Participant
ALLERGIES Food allergies: ___________________________________________________ Reaction: _______________________________ Medication allergies: ______________________________________________ Reaction: _______________________________ Other allergies: ___________________________________________________ Reaction: _______________________________ Does participant carry / use an EpiPen? Yes No * If yes, please contact NSSRA’ s Registrar for necessary form.
DIETARY INFORMATION Restrictions: ______________________________________________________________________________________________ G-tube: Yes * No * If yes, please contact NSSRA’ s Registrar to complete necessary form. Food preferences: _________________________________________________________________________________________ If over 21 years, can consume alcohol: Yes No Quantity: __________________________________________________
MEDICAL INFORMATION Permission to apply sunscreen: |
Yes |
No |
Permission to apply bug spray: |
Yes |
No |
Primary Physician: _______________________________________________________________ Phone: ________________________ |
Medical Insurance Company: ______________________________________________________ Policy #: _____________________ |
Please list all medications participant takes( if more than three, please attach list): Medication Name Dosage Time Purpose
* Any participant requiring medication during programs must complete necessary forms. Please contact NSSRA’ s Registrar.
MOBILITY / TRANSPORTATION Preferred pick up point( please select one): NSSRA WCRC RCHP / Moraine Can walk independently: Yes No
Uses wheelchair: If yes, what type: Manual Electric
Transfers independently Transfers with assistance Uses orthopedic equipment( walker, braces, canes, AFOs): ____________________________________________________ Requires a vehicle with a lift Requires staff assistance during transportation
COMMUNICATION NEEDS Verbal Non-verbal Limited Independent communication Assisted / Facilitated communication Uses sign language Hearing aid Uses communication system( PECS, picture schedule, talker): __________________________________________________
BEHAVIOR INFORMATION Best way to transition to new activity:______________________________________________________________________________ Best way to re-direct: ___________________________________________________________________________________________ Best way to calm: _______________________________________________________________________________________________ Behaviors exhibited when upset / frustrated:_________________________________________________________________________ Fears / phobias: _________________________________________________________________________________________________ Preferred activities: _____________________________________________________________________________________________ Does participant have a behavior plan? Yes No * If yes, please provide behavior plan.
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Register online at register. nssra. org.