PARTICIPANT NFORMATIONARTICIPANT INFORMATION WINTER/SPRING 2012
INTER/SPRING 2012
Both sides of the registration form MUST be completed and verifi ed by a signature before the participant is allowed to join any NWSRA program. Please check the correct response, complete each category and list any other information you feel NWSRA should be aware of to provide safe and enjoyable activities for the individual being registered.
SEIZURES: No____ Yes____ If "Yes", please complete seizure form. MEDICAL CONDITIONS/NEEDS: Diabetes____ Shunts____ Braces____ Canes____ Walker____ Glasses____ PKU____ G-tube____ VNS____ Trach____ Epi-pen____ Sign Language Assistance____ Hearing Aid____ Suctioning____ Catheter____ Does participant require assistance for personal care (toileting, transferring, feeding, changing)? Yes___ No___ (If yes, a personal care information form will be sent to you.)
If using a wheelchair is participant capable of transferring? Yes____ No____ Wheelchair (type)__________________________ AAI Condition: If a participant has Down syndrome, have x-rays of the C-1 and C-2 vertebrae been taken and examined? Yes___ No___ Date _____ Is participant clear of Atlantoaxial Instability Condition (AAI)? Yes____ No____ Allergies (specifi c)_______________________________________________________ Other ___________________________________________ List specifi c medical instructions: ____________________________________________________________________________________________ A permission form must be obtained, signed and returned to NWSRA in order for staff to assist with medications. Contact NWSRA to obtain a form. For participants not needing medication dispensed at programs but would like to make us aware, please list all medications. MEDICATION:
TYPE DOSAGE TIME
DOCTOR’S NAME:______________________________________________________________Phone (
) _____________________________
NWSRA provides an approximate 1:4 staff to participant ratio. Please note if participant requires a closer ratio and why: ______________________ _______________________________________________________________________________________________________________________ Inappropriate Activities: ___________________________________________________________________________________________________ Behavior Issues: _________________________________________________________________________________________________________ Areas/goals for the instructor to work toward: __________________________________________________________________________________ Release of information permission for NWSRA to contact school/workshop staff concerning the participant’s needs: Yes____ No____ NWSRA regards and treats personal information about participants as confi dential, except in certain unusual situations in which NWSRA may have a duty to provide such information to third parties in order to avoid unreasonable risks of harm to them or to other individuals in their care. Photo permission for NWSRA publicity purposes: Yes____ No____ Please indicate under what circumstances, if any, participant may be without leader supervision (i.e. to walk home from program, etc.) _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Parent/Guardian Signature:______________________________________________________(sign only if participant may be without supervision)
IS A BUS AIDE REQUIRED? Yes____ No____ Explain why: ____________________________________________________________________ IS A VEHICLE HARNESS REQUIRED? Yes____ No____ SWIM INFORMATION: Beginner____ Advanced Beginner____ Intermediate____ Advanced____ Diving____ Permission to apply sunscreen on participant: Yes____ No____ Other helpful information: _________________________________________________________________________________________________ YOUR INPUT HAS IMPACT!
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Please use the space below as a way to ask questions, make suggestions, voice concerns or even offer compliments! Your feedback will be read personally by an NWSRA staff member and we will do our best to give your ideas and needs our attention. Of course, there are times when we cannot fulfi ll every request due to available resources, but your request does not end there! Each season we review all requests that we were not able to accomplish the season before and reconsider the possibilities. If you would like to receive a written response, please check this box. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________
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