ARK Respite Registration Form
Participant's first and last name
I am participating as...
Teen/Young Adult (13-21)
Name of School Currently Attending
Table Mound Elementary
EMERGENCY CONTACT INFORMATION: Name
EMERGENCY CONTACT INFORMATION: Relationship to participant
EMERGENCY CONTACT INFORMATION: Address
EMERGENCY CONTACT INFORMATION: Cell phone number
EMERGENCY CONTACT INFORMATION: Email
Participant's t-shirt size
YOUTH extra large
ADULT extra small
Please check all that apply
Deaf and Hard of Hearing
Severity of diagnosis
Please describe the severity of any of the diagnosis checked above
Method of communication
If the participant uses an alternative method of communication, please describe below. (sign, augmentative device, ec.)
We will provide a snack. Please indicate what would be best for the participant.
Eats by mouth, independently
Needs some assistance
Eats only soft, blended food
Eats by G-tube
Please DO NOT give my child a snack or drink.
Please list favorite snack items that the participant could eat.
Does the participant have a medical plan (for example, seizure disorder) for emergency procedures?
Yes. (Please attach a copy for us. The same plan you use for school or daycare would be fine.)
Please list medications that are taken on a regular basis.
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.
Check all that apply:
Uses toilet independently
Uses toilet with supervision
Needs transfer assistance
Please list the participant's primary physician and hospital preference.
Please describe any special needs the participant has.
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.
Please list any additional comments that we need to know about the participant.
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