NSSRA Program Guides Winter 2019 | Page 65

BEHAVIOR INFORMATION, CONTINUED. Fears/phobias: __________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Preferred activities: ______________________________________________________________________________________________ ________________________________________________________________________________________________________________ Does participant have a behavior plan? Yes No *If yes, please provide behavior plan. SAFETY Able to say name? Yes No Able to consistently say phone number? Yes No Does participant wander/run from group? Yes No Sometimes Is participant responsible for own belongings? Yes No Sometimes Can participant manage own money? Yes No Sometimes Can participant recognize danger? Yes No Sometimes Does participant swim? Yes No Require 1:1 assistance in the water? Yes No Explain: ________________________________________________________________________________________________ Who is authorized to pick up participant from programs or events? __________________________________________________ DAILY LIFE SKILLS Requires assistance eating: _________________________________________________________________________________ Requires assistance in bathroom: ___________________________________________________________________________ Requires regular bathroom schedule: ________________________________________________________________________ Requires assistance dressing: _______________________________________________________________________________ Can participant read? Yes No Somewhat Can participant write? Yes No Somewhat ADDITIONAL INFORMATION Please share any additional information you feel is helpful: __________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ I grant photo permission for participant’s picture to be taken and used in NSSRA publications. Participant is independent and does not require supervision at conclusion of program/drop-off. Yes Yes No No ___________________________________________________________ ________________________ Signature of Participant/Parent/Guardian Date AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT I authorize NSSRA to arrange for emergency medical treatment, in the event of injury to my child or me and in the event that I or my designated emergency contact cannot be reached by NSSRA. ___________________________________________________________ ________________________ Signature of Participant/Parent/Guardian Date AUTHORIZATION TO CONTACT AND RELEASE INFORMATION Unless otherwise indicated in writing, I grant permission to NSSRA to contact the school, park district, teacher assistants, teacher, social worker, therapist or physician for the purpose of gathering or releasing information regarding the participant. The information will be used to develop the most effective plan for providing NSSRA recreation services and proper placement in inclusion. All information will be kept confidential. ___________________________________________________________ ________________________ Signature of Participant/Parent/Guardian Date Questions? Contact us at [phone] or [email protected]. www.nssra.org 65