Participant Information Form Page 2
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2Seizure Disorders – Does Participant have a history of seizures?
□ Yes
□ No
Likelihood and frequency of seizures:
Triggers:
Common behavior symptoms during seizure:
Desired first-aid procedures:
Please be advised, LEEP Staff will call 911 if a seizure lasts longer than 2 minutes.
Communication and Comprehension:
Dietary Concerns:
(Please List)
When given one/ two-step verbal directions, participant
(check one)
□ Always Understands
□ Sometimes Understands
□ Does Not Understand
Best way to communicate
(i.e.: verbally, using picture books, is non-verbal
)
General Concerns: (If any boxes are checked “yes”, please comment)
□ Yes
□ No
Physical Limitations/ Assistive Devices
□ Yes
□ No
Allergies
□ Yes
□ No
Personal Cares
□ Yes
□ No
Money Management
□ Yes
□ No
Fears/Phobias
□ Yes
□ No
Behavior Concerns
□ Yes
□ No
Aggression
Supervision:
Please explain length of time Participant can be left alone and type of supervision/setting required:
Is the Participant able to leave the group and go unsupervised on specific LEEP outings?
□ Yes
□ No
Controlled Substance Use
(based on LEEP’s policies):
Is the Participant allowed to drink any alcohol? □ Yes
□ No
If Yes, please describe the type and amount of alcohol:
Is the Participant allowed to smoke cigarettes? □ Yes
□ No
If Yes, please describe frequency:
Please complete both sides entirely and return with Participant Information Signature Page.
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