Synergy Annual Information Form

SYNERGY ANNUAL INFORMATION FORM

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

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2020 Synergy Annual Information Form
Name*
First Last
Birth Date*
MM slash DD slash YYYY
Gender*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Athlete Cell Phone*
Athlete Email*
School/Employer/Agency
Do you pay Park District taxes?*
- Yes
- No
Athlete Shirt Size*
Athlete's Primary Language
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
Parent/Guardian #1 First Name
First Last
Cell Phone
Employer
Primary Language
Parent/Guardian #2 First Name
First Last
Cell Phone
Employer
Primary Language
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
Cell Phone
Town of Residence
Military/Veteran
Are you active duty military, a veteran, or first responder?
- Active duty military
- Veteran
- First Responder
Service Branch (List all Applicable)
Disabilities
Primary Diagnosis*
Level/Severity
Secondary Diagnosis
Level/Severity
Congenital/Acquired?
Date Acquired
Do you have a service animal?
Animal Name
What service does this animal provide for you?
Mobility
Adaptive Equipment
- Ambulatory without any assistive device
- Ambulatory with assistive device
Adaptive Equipment (check which ones apply)
- AFO/SMO
- Cane/Crutches
- Walker
- Prosthesis (AK)
- Prosthesis (BK)
- Prosthesis (AE)
- Prosthesis (BE)
- Use a manual wheelchair for all mobility
- Use a power wheelchair for all mobility
- Use a manual wheelchair only/primarily for longer distances or difficult terrain
- Use a power wheelchair only/primarily for longer distances or difficult terrain
Please describe how you transfer from your wheelchair and/or what assistance you need to transfer (if applicable)
If athlete requires assistance in transferring and is a minor, a Transfer Plan Form must be completed.
Hard of Hearing/Deaf
Which ear?
Wears hearing aid in which ear?
Needs a sign language staff during programs? (if available)
- Yes
- No
Communication-Select all that apply
- Verbal and clearly understood
- Verbal but not clearly understood
- Non-verbal ¨
- Able to Read
- Able to Write
- Uses Communication Device
Travel- How will you most often travel to/from programs?
- Personal vehicle (yours or a ride)
- Public Transportation
- PACE/Paratransit
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/athlete self-administer your/their medication?
- Yes
- No
Permission for WDSRA staff to administer medication during program/trips?
- Yes
- No
Doctor Restrictions
Does the athlete 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.
Please check if any of the following apply:
- Do you have a history of diabetes?
- Do you use insulin?
- Have you been diagnosed with asthma?
- Do you use a rescue inahler?
Daily Living Skills
Please describe any assistance needed with eating:
Please describe any assistance needed from staff with toileting:
Do you use a catheter? (Synergy staff cannot assist with catheters)
- No
- Yes
Releases
If over 21, permission for athlete to consume alcohol during program/trip (2 drink maximum)
- Yes
- No
Permission for Synergy/WDSRA staff to allow participant to remain after programs independently?
- Yes
- No
Permission for Synergy/WDSRA staff to share participant name and phone number as part of team roster to share with other participants?
- Yes
- No
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
Household Income
Household Income
Household Income
Household Income
Household Income
Household Income
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

SYNERGY ANNUAL INFORMATION FORM

2020 Synergy Annual Information Form

Primary Program Contact Information

Parent/Guardian General Information

Emergency Contact

Military/Veteran

Disabilities

Mobility

Hard of Hearing/Deaf

Allergies

Dietary Restriction

Medication/Medical

Daily Living Skills

Releases

Demographics

Ethnicity