Accessible Recreation Participant Profile

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?

Leave This Blank:


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