Participant Registration And Release Form - Dcr Universal Access Progra (Page 2 of 2) in pdf

Participant Registration And Release Form - Dcr Universal Access Progra Page 2

2016 PARTICIPANT REGISTRATION FORM

General Information:

Name: ________________________________________________Birth date: _______________________

Emergency Contact: _____________________________________ Phone Number ____________________

Medical Information

Please complete this information to help us better serve you. Please check any that apply.

__Seizure Disorder __Heart Disease __Diabetes

__Traumatic/Acquired Brain Injury __Bleeding Disorder __Lung or breathing disorder

__High Blood Pressure __Life Threatening Allergies __ Dementia

__Weakness or Paralysis of Extremities: __Left __Right

__Other (Please explain): __________________________________________________________________

Please explain any medical information checked________________________________________________

_______________________________________________________________________________________

Confidential Questions

So we can better serve your needs, please complete the following:

Height_______ Weight_______

__Yes __No Can you independently form a watertight seal with your mouth?

__Yes __No Can you independently hold your head up in the water?

__Yes __No Can you independently turn face up in the water while wearing a life jacket?

__Yes __No Can you alert program staff to your needs?

__Yes __No Will you be able to refrain from behaviors that pose a risk to yourself and/or

others? (i.e. Pica, aggression, lack of safety awareness, wandering away from the group)

__Yes __No Will a Personal Care Assistant accompany you?

If yes, please provide his/her name_______________________________

___Yes ___No

Do you carry any medication?

If yes, please describe_________________________________________

Please offer any additional information you feel program staff should be aware of for your safety

and comfort, including any special accommodations needed:

__________________________________________________________________________________________

Participant Registration And Release Form - Dcr Universal Access Progra Page 2