Recreation Registration

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Registration Form

Date

Facility

Child's Name

Sex

Date of Birth

Mailing Address

City, State, Zip

Mother's Name

Home Ph

Cell Ph

Fax

Work Ph

Address (if different from above)

Father's Name

Home Ph

Cell Ph

Fax

Work Ph

Address (if different from above)

Emergency Contact 1

Name other than parent

Home Ph

Cell Ph

Relationship

Emergency Contact 2

Name other than parent

Home Ph

Cell Ph

Relationship

Child's current primary phyician

City

Phone

Child's Medications / Restrictions

Child's medical diagnosis

Is there any contraindictions (i.e., medications, activities, foods, etc) that should be avoided?

Does your child have a history of seizures?

Yes

If yes then answer the 4 questions below.

1. When was the most recent seizure?

2. What type of seizure(s) has your child experiencd

3. What medication(s) have been prescribed?

4. Please list all child's illnesses/diseases:

Does your child receive behavioral intervention (ie., ABA)?

Does your child demonstrate inappropriate behavior?

Yes

If answered above yes then what behaviors?

How would you best describe the way your child learns (ie., visual, auditory, cues, etc) ?

What, if anything could cause your child to demonstrate self-stimulatory behaviors?

What situations, events, and/or types of stimuli could cause your child to have a meltdown?

When/if your child has a meltdown, how long does it typically last?

Is your child able to organize his or her behavior after a meltdown and return to task?

Does your child react to other children in a social setting?

In your opinion, does your child get frustrated easily? Frequently?

Does your child display mild temperament and self-organize easily?

Does your child get excited easily?

If yes, once excited, is it hard for him or her to reorganize?

Does an excited state often lead to a meltdown?

If you are human, leave this field blank.

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