2. Participant Contact Information
4. Name
6. Gender
   -- Select One --FemaleMale
7. Age
8. Birthdate
10. Address
12. City
13. State
14. Zip Code
16. Home Phone
17. Work Phone
18. Cell Phone
22. Emergency Contact
24. Name
26. Relation
27. Primary Phone
28. Alternative Phone
32. Participant Details
34. Participant's Disability
36. What are the participant's goals for this program?
38. Fears the participant might have
39. Activities the participant enjoys.
41. List any activities the participant should not participate in due to medical conditions.
43. Best ways to motivate the participant
44. Describe social interactions
46. Allergies, food restrictions, or special diet (i.e. diabetic)
48. Is the participant prone to having seizures?

    1. Yes
    2. No
49. If yes:
    Please indicate type of seizure, duration, warning signs, desired action, first aid in the event of a seizure during a program.
51. If seizure occurs, contact person and phone number
53. What other needs does the participant have that we should be aware of?
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55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field