Synergy Annual Information Form

2020 Synergy Annual Information Form

Name*

First Last

Birth Date*

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)

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

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*

Synergy Annual Information Form