Form Center

2. 
4. Name Of Participant*
5. D.O.B*
7. Parent Name*
8. Email*
10. Address*
11. Phone Number*
13. Emergency Contact (Name)
14. Emergency Contact Number
16. School Name (If Applicable)
17. Grade
21. WHAT KIND OF SUPPORT IS NEEDED?

    1. None
    2. Assistance with fine motor tasks (cutting, pencils skills)
    3. Assistance/adaption with gross motor tasks (running, sports)
23. Other
27. WHAT IS THE PARTICIPANT'S PRIMARY MEANS OF COMMUNICATION?

    1. Speaks and understood by others
    2. Speaks, but difficult to understood
    3. No means of verbal communication
    4. Sign language
    5. Communication board
29. Other (eyes, gestures, etc.)
33. MEDICAL/DIETARY INFORMATION
35. Does the participant have seizures?

    1. Yes
    2. No
37. If yes, describe type, (petit or grand mal) frequency, duration and warning signs
39. Desired seizure first aid procedures for this participant.
41. First: Dial*911/Call Parent
43. List dietary restrictions/allergies/other medical conditions staff should be aware of.
45. NB: ALL INFORMATION ON THIS FORM IS CONFIDENTIAL AND WILL ONLY BE SHARED WITH STAFF
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field