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Participant Annual Information Form
Participant Annual Information Form
wdsra-admin
2017-06-27T18:31:57-06:00
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
2020 Participant General Information
Name
*
First
Last
Birth Date
*
Date Format: MM slash DD slash YYYY
Gender
*
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
*
Are you your own guardian?
Yes
No
Primary Program Contact Information
This information will be used 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
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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
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
Verbal and clearly understood
Verbal but not clearly understood
Non-verbal ¨
Able to Read
Able to Write
Uses Communication Board/Book
Uses iPad to communicate
Other communication devices-Explain below
Uses sign language
Uses homemade sign language
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 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.
Household Size
Not Provided
1
2
3
4
5
6
7
8 or more
Household Income
$18,720 or less
$31,200
$37,440
$49,920+
Household Income
$21,390 or less
$35,650
$42,780
$57,040 +
Household Income
$24,060 or less
$38,100
$45,720
$64,160 +
Household Income
$26,730 or less
$44,550
$53,460
$71,280 +
Household Income
$28,890 or less
$48,150
$57,780
$77,040 +
Household Income
$31,020 or less
$51,700
$62,040
$82,720 +
Household Income
$33,150 or less
$55,250
$66,300
$88,400 +
Household Income
$35,310 or less
$58,850
$70,620
$94,160 +
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
*
Date Format: MM slash DD slash YYYY