Participant Annual Information Form

PARTICIPANT ANNUAL INFORMATION FORM

The Western DuPage Special Recreation Association requires that an Annual Information Form to be completed yearly in order to participate in recreational programs

2023 Participant General Information
Name*
First Last
Birth Date*
MM slash DD slash YYYY
Gender*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County*
County
Home Phone
Cell Phone
Email*
School/Employer/Agency
Do you pay Park District taxes?*
- Yes
- No
Participant Shirt Size*
Are you your own guardian?*
- Yes
- No
Primary Program Contact Information
This individual will be the primary contact for all program phone calls, calling posts, and email communication.
Name of Contact
Phone
Email*
Parent/Guardian General Information
Third Party Payment
Billing Address (if different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Guardian #1 First Name
First Last
Cell Phone
Employer
Position
Work Phone
Parent/Guardian #2 First Name
First Last
Cell Phone
Employer
Position
Work Phone
Emergency Contact
Please give the name of a relative or friend who can respond for your family member in case of an emergency when you cannot be reached.
Name*
Relationship
Home Phone
Cell Phone
Disability/Diagnosis
Primary*
Secondary
Adaptive Equipment (check which ones apply
- N/A-Ambulatory
- Wheelchair: Electric
- Manual
- AFO/Splints/Braces
- Cane/Crutches
- Walker
- Other
If participant uses a wheelchair a transfer plan form must be completed
If Other, explain below
Special Instructions on Orthopedic Equipment
Hard of Hearing/Deaf
Which ear?
Wears hearing aid in which ear?
Needs a sign language staff during programs?
- Yes
- No
Communication
- Verbal and clearly understood
- Verbal but not clearly understood
- Non-verbal ¨
- Able to Read
- Able to Write
- Uses iPad to communicate
- Other communication devices-Explain below
- Uses sign language
- Uses homemade sign language
- Uses visual supports (communication board, first/then)
Other Communication Devices-Explain
Allergies
Allergy
Reaction
Treatment
Allergy
Reaction
Treatment
Dietary Restriction
Please list any dietary restrictions
Medication/Medical
Please provide us with a list of the current medication being taken. This information is used in emergency situations. If medication is given at a program, an additional form needs to be completed. Any prescription or over the counter medication taken during WDSRA programs/trips must be in a WDSRA medication envelope. Each envelope must be labeled with Participant name, date, time to be taken and the number of pills.
Can you/participant self-administer their medication?
- Yes
- No
Permission for WDSRA staff to administer medication during program/trips?
- Yes
- No
Doctor Restrictions
Does the participant have seizures?
- Yes
- No
If yes, a seizure questionnaire must be completed. Please know that if there are any medical concerns or unusual presentations, 911 may be called.
Daily Living Skills
Can Eat:
- Independently
- Independently with reminders
- Only with assistance
- Cannot feed self
- Cannot choose and order meals
- Unable to follow prescribed diet
- Unable to cut own food
- Doesn’t know food to avoid
- Does not chew food completely
Can Toilet:
- Independently
- Independently with reminders
- Only with assistance
- Cannot manipulate clothing
- Transfers on/off toilet
- Unable to sit on toilet
- Unable to manipulate & use toilet tissue
- Uses modified adult undergarment
- Females: Assistance needed with menstrual care
Additional Info
Able to manage spending money?
- Yes
- No
Explain
Behavioral
- Easily distracted
- Manipulative/Challening
- Self-injurious
- Aggressive
- Tantrums/Meltdowns
- Verbal Outbursts
Explain
Complies with verbal requests and directions?
- Yes
- No
Responds to specific verbal/non-verbal directions?
- Yes
- No
Responds to positive reinforcement?
- Yes
- No
Sensory
Does participant have sensitivity issues?
- Yes
- No
Please Describe
Does participant seek sensory input?
- Yes
- No
Please Describe
Releases
If over 21, permission for participant to consume alcohol during program/trip? (2 drink maximum)
- Yes
- No
Permission for WDSRA staff to allow participant to remain after programs independently?
- Yes
- No
Permission for WDSRA to print participant name, address, phone number in a Phone Book and/or Athletic Team Roster to share with other participants ?
- Yes
- No
Swim Information
Does participant know how to swim?
- Yes
- No
Use flotation device?
- Yes
- No
Use ear plugs?
- Yes
- No
Is participant allowed to swim in deep water?
- Yes
- No
Helpful Suggestions
Share any information that would help WDSRA to work successfully with your participant. (Communication, fears, positive reinforcement suggestions, behavior management, and other helpful hints. Please attach a separate piece of paper if needed.)
Demographics
Grants help us keep the cost of programs down. Some of our grant applications require that we provide demographic information on the families/participants that use our services. This information is used for grant purposes only. This section is optional.
How many individuals reside in our household?
Total Household Income
Total Household Income
Total Household Income
Total Household Income
Total Household Income
Total Household Income
Total Household Income
Total Household Income
Ethnicity
Ethnicity (check all that apply)
- I do not wish to furnish this information
- Hispanic or Latino
- Non-Hispanic or Latino
Race
- American Indian or Alaska Native
- Native Hawaiian or Other Pacific Islander
- Asian
- White
- Black or African American
Signature*

By typing your name in the field above and clicking submit, you agree that the above information has been completed to the best of your knowledge. If your participant is under 18 you this must be signed by the parent/guardian.
Date*
MM slash DD slash YYYY

PARTICIPANT ANNUAL INFORMATION FORM

2023 Participant General Information

Primary Program Contact Information

Parent/Guardian General Information

Emergency Contact

Disability/Diagnosis

Hard of Hearing/Deaf

Allergies

Dietary Restriction

Medication/Medical

Daily Living Skills

Sensory

Releases

Swim Information

Helpful Suggestions

Demographics

Ethnicity