Participant Annual Information Form

2019 Participant General Information

Name*

First Last

Birth Date*

Gender*

Male
Female

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Email*

School/Employer/Agency

Do you pay Park District taxes?*

Yes
No

Participant Shirt Size*

Primary Program Contact Information

This information will be used for all program phone calls, calling posts, and email communication.

Name of Contact

Phone

Email*

Are you your own guardian?

Yes
No

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

Mother's Name

First Last

Cell Phone

Employer

Position

Work Phone

Father's 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

Disabilities

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

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 (including but not limited to, Grand Mal Seizure), 911 will 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
Self-abusive
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

Does participant use visual supports?

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, birthdate, 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 son/daughter regarding communication, fears, positive reinforcement suggestions, behavior management, and other helpful hints.

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.

Household Size

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.

Date*

Participant Annual Information Form