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Initial Registration Form for Ages 15 to Adult
Thank you so much for your interest in the SO MUCH TO GIVE INSPIRATION STUDIO!
Please complete this form to the best of your ability with as much detail as possible. Please note that you only need to fill this out ONE TIME per individual participant. Once your information is reviewed, the participant will be in our system, and you will be contacted as to how to sign up for sessions.
Should you have any general questions,
please e-mail Suzanne at InspirationStudioSMTG@gmail.com. Should you wish to discuss a participant's specific needs, please feel free to contact me directly. We are dedicated to doing everything we can to enrich and enhance the lives of those who spend time with us!
Sincerely,
Maureen Stanko
Director of Programming
SomuchtogivePA@gmail.com
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Email
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Your email
Name of Person Completing Form:
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Your answer
Relationship to Applicant
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Parent
Caregiver/Legal Guardian
Self
Required
Cell phone number of person completing this form:
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Your answer
Applicant's Name (If different from above)
Your answer
Applicant's Full Address:
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Your answer
Participant’s Date of Birth:
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Your answer
Please check all areas of interest of participant:
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coloring/drawing/painting
making crafts
dancing
singing
puzzles
playing lawn games
playing board games
helping around the house
cooking
playing Bingo
going out to eat
watching movies
trivia
exercising
Other:
Required
Please help us to learn more about the applicant’s diagnoses and provide any information that will be helpful for us to know. If the participant has communication difficulties, please describe.
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Your answer
Please share all
areas of strength of applicant with as much detail as possible.
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Your answer
Does participant need 1:1 assistance or supervision for any of the following? (Please indicate with a check if yes.)
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toileting
attention/focus
safety (flight risk, pica, etc.)
safety (risk of self-injury/harm to others)
Other:
Required
Please list any known allergies (foods, medications, environmental) as well as interventions should an exposure occur.
Please also list any medications that participant would need to self-administer while attending classes or events. Please be advised that staff are not permitted to administer medications.
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Your answer
Does participant currently display any behaviors that could potentially cause harm to self and/or others? If so, please list and explain and behaviors of concern (Examples: kicking, biting, elopement, hitting, pica, etc.)
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Your answer
Please explain any triggers that might cause upset as well as de-escalation strategies (if applicable):
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Your answer
Inspiration Studio activities will be staffed at a 5:1 ratio. Will this be appropriate to meet the needs of participant in a "drop off" situation? Please explain below.
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Your answer
Will participant need to be in attendance with a parent or caregiver in order to have a safe and productive experience? (All are welcome!) Please explain your answer below.
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Your answer
Please let us know how we can we best help the participant socially. Is there anything in particular that you would like us to be working on? What other programs have been beneficial for the participant?
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Your answer
If student is interested in music, please list favorite artists/bands/genres of music they enjoy.
Your answer
Please share any other information that you feel may be important for us to know in order for us to best serve the participant. (Please know that if something is relevant to you, it will be relevant to us!)
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Your answer
THANK YOU FOR YOUR INTEREST!
So Much to Give Inspiration Studio
A copy of your responses will be emailed to the address you provided.
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