Participant Medical Information Form - Cobb County Parks, Recreation & Cultural Affairs Department Therapeutic Recreation Services
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2COBB COUNTY PARKS, RECREATION & CULTURAL AFFAIRS DEPARTMENT
THERAPEUTIC RECREATION SERVICES
Participant Medical Information
This form will expire in two years.
Date____________________________
It is imperative that you notify us of any changes in condition or medications during the year.
If registering more than one participant, please complete an additional form for each registrant.
This form must be completely filled out before we will register the participant.
Participant Information
Participant’s Name (Last)______________________________ (First)___________________________________
Participant’s Residence Address_______________________________________________ City_______________ Zip________________
Home # (____)_____________________________ Work # (____)______________________________
Female___ Male___ Age_____ Birth date__________ Participant e-mail________________________________
Caregiver Name_____________________ office # (___)_______________ cell # (___)________________
Parent E-Mail___________________________________________________________________
Circle All That Apply: Mild Intellectual Disability
Moderate Intellectual Disability
Severe Intellectual Disability
Profound Intellectual Disability
Emotional & Behavioral Disorder
Specific Learning Disability
Orthopedic Impairment
Hearing Impairment
Other Health Impairment
Visual Impairment
Speech-Language Impairment
Autism
Traumatic Brain Injury
Autism Spectrum
Pervasive Developmental Delay
Attention Deficit/Hyperactivity Disorder
Attention Deficit Disorder
Fragile X Syndrome
Autism Spectrum
Other medical condition(s)________________________________________________________________________________________
Parent/Guardian Information
Mother’s Name______________________________ Father’s Name_____________________________________
Address
____________________________________________________________________
(if different from above)
Mother’s Home Phone (_____)____________Work Phone (____)__________________
Cell Phone( )______________
Father’s Home Phone (_____)_____________Work Phone (____)__________________
( )___________
Cell Phone
Alternate Emergency Contact______________________ Relationship to Participant________________________
Home Phone (____)____________________________ Work Phone (____)_______________________________
PARTICIPANT INFORMATION:
Please check or circle the correct response, complete each category and list any other information you feel
CCPRCAD should be aware of to provide safe and enjoyable activities for the individual being registered.
MEDICAL CONDITIONS: Diabetes
Shunts
Braces/Canes/Walker
Hearing Aid
Ear Tubes
Needs Interpreter
Glasses
Wheelchair (type)__________________ Non-Verbal Communication___________________
Allergies (specific)______________________________ Other________________________________________________
SEIZURES: Yes___ No___
Epilepsy Yes___ No___
Are seizures controlled by medication? Yes___ No___
Date of last seizure: ____________ Type of seizure and treatment desired:________________________________________
MEDICATION: Type, Dosage/Time___________________________ Type, Dosage/Time__________________________
Comments___________________________________________________________________________________________
For participants needing more assistance than a reminder to take prescribed medication, please check _____. A permission
form must be obtained, signed and returned to CCPRCAD in order for staff to assist. Contact CCPRCAD to obtain a form.
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Parent category: Medical