ARK Respite Registration Form
Participant's first and last name *
Your answer
Particpant's nickname
Your answer
I am participating as...
Gender *
Required
Birthdate *
MM
/
DD
/
YYYY
Name of School Currently Attending *
EMERGENCY CONTACT INFORMATION: Name *
Your answer
EMERGENCY CONTACT INFORMATION: Relationship to participant *
Your answer
EMERGENCY CONTACT INFORMATION: Address *
Your answer
EMERGENCY CONTACT INFORMATION: Cell phone number *
Your answer
EMERGENCY CONTACT INFORMATION: Email
Your answer
Participant's height
Your answer
Participant's weight
Your answer
Participant's t-shirt size *
Child's diagnosis
Please check all that apply
Severity of diagnosis
Please describe the severity of any of the diagnosis checked above
Your answer
Communication *
Method of communication
If the participant uses an alternative method of communication, please describe below. (sign, augmentative device, ec.)
Your answer
Food *
We will provide a snack. Please indicate what would be best for the participant.
Required
Snack preference
Please list favorite snack items that the participant could eat.
Your answer
Medical plans *
Does the participant have a medical plan (for example, seizure disorder) for emergency procedures?
Medications *
Please list medications that are taken on a regular basis.
Your answer
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.
Your answer
Toilet/Hygiene Needs *
Check all that apply:
Required
Contact/Community Assistance *
Please list the participant's primary physician and hospital preference.
Your answer
Special needs
Please describe any special needs the participant has.
Your answer
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.
Your answer
Additional Comments
Please list any additional comments that we need to know about the participant.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms