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Synergy Annual Information Form

Synergy Annual Information FormSteve Eckelberry2020-07-30T10:10:31-05:00

SYNERGY ANNUAL INFORMATION FORM

Synergy requires that an Annual Information Form to be completed yearly in order to participate in recreational programs
  • Hidden

    2023 Synergy Annual Information Form

  • MM slash DD slash YYYY
  • Primary Program Contact Information

    This information will be used for all program phone calls, calling posts, and email communication.
  • Parent/Guardian General Information

  • 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.
  • Military/Veteran

  • Disabilities

  • Mobility

  • If athlete requires assistance in transferring and is a minor, a Transfer Plan Form must be completed.
  • Hard of Hearing/Deaf

  • Allergies

  • Dietary Restriction

  • Medication/Medical

    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

  • Releases

  • 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.
  • Ethnicity

  • 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.
  • MM slash DD slash YYYY

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116 N. Schmale Road
Carol Stream, IL 60188-2103
P: 630-681-0962
F: 630-681-1262
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