ARK Respite Registration Form

Participant's first and last name

This is a required question

Particpant's nickname

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I am participating as...

Child (3-12)
Teen/Young Adult (13-21)

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Gender

Male
Female

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Birthdate

Name of School Currently Attending

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EMERGENCY CONTACT INFORMATION: Name

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EMERGENCY CONTACT INFORMATION: Relationship to participant

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EMERGENCY CONTACT INFORMATION: Address

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EMERGENCY CONTACT INFORMATION: Cell phone number

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EMERGENCY CONTACT INFORMATION: Email

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Participant's height

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Participant's weight

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Participant's t-shirt size

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Severity of diagnosis

Please describe the severity of any of the diagnosis checked above

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Communication

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Method of communication

If the participant uses an alternative method of communication, please describe below. (sign, augmentative device, ec.)

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Food

We will provide a snack. Please indicate what would be best for the participant.

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Snack preference

Please list favorite snack items that the participant could eat.

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Medical plans

Does the participant have a medical plan (for example, seizure disorder) for emergency procedures?

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Medications

Please list medications that are taken on a regular basis.

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Allergies

List an allergies (including food allergies). Describe the severity of each and list the action steps to be taken in the event the participant has an allergic reaction.

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Toilet/Hygiene Needs

Check all that apply:

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Contact/Community Assistance

Please list the participant's primary physician and hospital preference.

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Special needs

Please describe any special needs the participant has.

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By typing your name below you understand and agree to the waiver explained below.

WAIVER: In consideration of being permitted to participate in this event, I hereby for myself, my heirs, and personal representatives assume any and all risks which might be associated with the event. I further waive, release, discharge, and covenant not to sue ARK Advocates, its officers, employees, sponsors, organizers, volunteers, or other representatives, or their successors and assigns, for any and all injuries or damage of any kind whatsoever suffered as a result of taking part in the event and/or any related activities. I also agree to the use of any photo, film, or videotape of the event for any purpose chosen by ARK Advocates in support of their mission.

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Additional Comments

Please list any additional comments that we need to know about the participant.

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