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:_________________________________________________________________________
_______________________________________________________________________________________________________________
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Register online at register.nssra.org.