Participant Information Form
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2Participant Information Form
The Data Practices Act requires that we inform you of your rights about the private data we are requesting on this form. Private data is available to you, but not
to the public. This information can be shared with LEEP staff, Employment or Housing Support Agencies, and /or Direct Care Staff to better accommodate
consumers. You can withhold this data, participation is our programs is voluntary. Completing this form indicates you understand these rights and frees LEEP
from any liability in case of an accident.
Signature________________________________________________________________________________Date_________________
Last Name: _______________________________ First Name: ___________________________ Middle Name: _____________
________
Address:
City: _____________________________________ State: ___________ Zip: ______________ Birth date:
/
/
County of Residence: _______________ Home Phone:
Cell Phone:
□
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Male
Female
Email:
Work (optional):
P:ol
Health/Accident Insurance Company:
Policy #:
Living Situation: (Please Check Box)
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Independent
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Semi-Independent (complete below)
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Other____________________
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Parents’ Home
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Foster Home (complete below)
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Group Home (complete below)
Wo_________
Provider Name: ________________________________________ Residential Coordinator:
Phone:
Cell Phone:
On-Call Phone:
Email:
Emergency Contact Other than above (required):
Name: _____________________________________ Phone: __________________________ Other Phone: ________________
Legal Guardian:
Guardian Name:
Relationship:
Address:
City:
State:
Zip:
Home Phone:
Work Phone: _________________________ Cell Phone:
Primary Contact (required) Who should LEEP contact regarding payments, behavior incidents, injuries, etc.? Please check one.
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Participant
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Guardian
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Residential Coordinator
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Emergency Contact
Other
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Diagnosis (please be specific and list all)
Please complete both sides entirely and return with Participant Information Signature Page.
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