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LSF Respite Family Night Participant Information Form
LSF Respite Family Night Participant Information Form
*
required
Please fill out for each individual with special medical, emotional, physical, behavioral or cognitive needs.
Personal Information
Name
*
Name
First
First
Last
Last
Preferred Name
Birthday
*
Dropdown
*
Male
Female
Address
Parent/Guardian Information
Marital Status
Married
Divorced
Separated
Single parent
Parent/guardian #1:
Name
*
Name
First
First
Last
Last
Email Address
*
Phone
*
Parent/guardian #2:
Name
Name
First
First
Last
Last
Email Address
Phone
Sibling Information
Please fill out for each sibling under the age of 18.
Sibling #1:
Name
Name
First
First
Last
Last
Birthday
Sibling #2:
Name
Name
First
First
Last
Last
Birthday
Sibling #3:
Name
Name
First
First
Last
Last
Birthday
Sibling #4:
Name
Name
First
First
Last
Last
Birthday
Additional Siblings (Please list names and birthdates of any additional siblings under 18.):
Is there anything we should know about any of the kids/teens listed?
Emergency Contacts
Please list at least one person who is NOT a parent/guardian.
Emergency Contact #1:
Name
*
Name
First
First
Last
Last
Phone Number
*
Emergency Contact #2:
Name
Name
First
First
Last
Last
Phone Number
Care Information
Please give us as much information as you are comfortable sharing. This information will ONLY be shared with trained staff and volunteers who need the information to best care for the participant.
Diagnosis – OPTIONAL:
This will not be shared with volunteers, and a diagnosis is not required to participate in Arise activities.
Vision
*
Normal
Impaired
Wears corrective lenses
Hearing
*
Normal
Impaired
Deaf
Wears hearing aids
Cochlear Implant
Communication
*
Verbal
Sign Language
Gestures
Communication Device
Not yet communicating
Other
Communication Notes:
Signs used (please provide list), type of communication device, specific phrases to look for, etc.
Ambulation
*
Walks
Crawls
Uses walker/crutches
Uses wheelchair
Toileting (Check all that apply)
*
Wears underwear
Wears pull-ups/diapers
Sits on the toilet
Initiates independently
Goes on a schedule
Needs to be asked or reminded
How does the participant indicate that he/she needs to use the bathroom? Does this participant have any dietary restrictions? (Check all that apply)
None
Gluten free
Dairy free
Food allergies (list below)
Only food from home
Pureed only
Tube fed
Other
Other dietary restrictions:
Please list all allergies:
Are any of these allergies life-threatening?
Yes
No
I will supply an Epi-Pen.
Yes
No
Allergy Notes:
Has the participant had a seizure IN THE PAST?
Yes
No
Does the participant CURRENTLY have seizures?
*
Yes
No
If yes, please describe (Frequency/duration, protocol, medications used, type and symptoms, etc.):
Does the participant eat inedible objects? (Play-doh, crayons, etc.)
Yes
No
Preferences & Behavioral Concerns
What does this participant enjoy?
What would they play with at home? What do they enjoy learning about or talking about?
What does the participant dislike?
Do they have any fears or sensitivities? What upsets them?
Behaviors he/she might display:
Tantrums
Hitting
Kicking
Biting
Pinching
Eloping/Running
Self-injury
Spitting
Flopping on floor
Removing clothing
Hair pulling
Other (explain below)
Other behaviors:
What typically triggers these behaviors?
What is the best way to handle these behaviors?
Anything else you would like us to know?
If you are human, leave this field blank.
Submit
