Participant Information Form Today’s Date:______
Participant’s Name: (First)______(Last) ______
Date of Birth: ______/______/______T-Shirt Size: ______
Does Participant live (circle one): independently / with family / in a group home / other
Participant’s Current Address:______
City: ______Zip:______
Participant’s Home Phone: ______Participant’s cell phone: ______
Participant’s email address:______
Contact Information:
Main Contact Name:______
Relationship to participant: ______
Best Phone Number(s): ______
Best Email Address(es): ______
Please circle the best way to communicate:Email Text Phone Mail
Contact Two Name: ______
Relationship to participant: ______
Best Phone Number(s): ______
Contact Three Name: ______
Relationship to participant: ______
Best Phone Number(s): ______
Contact Four Name: ______
Relationship to participant: ______
Best Phone Number(s): ______
We are interested in learning more about:
Evening Gatherings Daytime Activities Special Events Camp
Personal Information
Participant’s Intellectual/Developmental Disability:______
Other Relevant Diagnoses (including Mental Health): ______
Does the participant have seizures? ______If yes, please fill out our seizure specific information form.
Allergies and/or Food Restrictions: ______
Please indicate (with an X) if it is NOT ok for Reality Staff to provide any of the following meds (PRN): ____ Aspirin ____Ibuprofen ____Benadryl ____Acetaminophen (Tylenol)
Please list any medications the participant is currently taking*:______
______*If medications change, it is important to let staff know.
Swim Level: (1) Should not get in water (2) Needs Assistance Swimming (3) Independent swimmer
Approximate reading level: (1)Non-reader (2) Early Elementary (3) Late Elementary (4) Fluent Reader
Participant’s School: ______Grade: ______
Regular daily or weekly activities (Job(s), Volunteering, Hobbiesetc.):______
______
Please describe helpful ways to respond if the participant gets frustrated or upset: ______
Please share any other information you think would be helpful for us to know:______
______
How did you hear about Reality Ministries? ______
Permission Release
--To be filled out by parent/guardian or by participant (if own legal guardian).--
I give Reality Ministries permission to use my/my child’s name and/or picture inpresentations, media releases, newsletters and marketing materials solely for the purpose of promoting Reality Ministries.
I give Reality Ministries permission to release basic information (contact info, allergies, and pertinent medical information or conditions to volunteers as deemed necessary and appropriate by the Reality Ministries staff.
I agree to release Reality Ministries, its staff and volunteers, from all liability for any accidental injury to me/my child or my/his or her possessions during Reality Ministries events.
I give my permission to the medical personnel selected by the Reality Ministries staff to order hospitalization, treatment, anesthesia and surgery if necessary in case of an emergency when parents cannot be reached.
I give permission to all male and female staff and volunteers designated by Reality Ministries to provide transportation for me/my child. Further, I agree to release Reality Ministries from all liability for any accidental injury to me/my child or my/his or her possessions while using this transportation.
Please state any special instructions pertaining to the permission release here: ______
Print Name: ______
Signature: ______Date: ______