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LIVDAYPROGRAM PARTICIPANT FORM
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* Indicates required question
Email
*
Your email
Participant's Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Address
*
Your answer
Primary Contact
*
Name, Relation, Telephone, Email
Your answer
Emergency Contact
*
Name, Relation, Telephone, Email
Your answer
Which days are you interested in attending? (select all)
*
Mondays
Tuesdays
Thursdays
Required
Motor Skills (Walking)
Independent
With Assistance
Dependent (Wheelchair)
Stairs
Independent
With assistance
NA
Describe Participant's Toilet Routine
*
Your answer
Eating and meal routine ( Check all that apply)
Eats independently
Needs reminders when eating
Needs physical assistance to eat
Eating and meal routine (Check all that apply)
Stays seated during meals
Uses fork or spoon to eat
Uses knife to eat
Uses fingers to eat
Uses regular cup to drink
Requires straw to drink
Has a poor appetite at times
Wants to eat all the time
Specific diet, food allergies or intolerances
Your answer
Add any comments about eating and meal routine
Your answer
Changing/Dressing
Independent
Requires Assistance
Clear selection
Add any comments about changing/dressing that are necessary
Your answer
Communication
Words
Gestures
Sign Language
Pen/Paper
Facial Expressions
Do they:
Respond to their name ( Stop activity and looks at you)
Respond when they are told NO
Understand simple instructions (eat, drink, come here, stop)
Understand two step instructions (go to the kitchen and bring a cup)
Ask for what they want ( food, drink, toy)
Let you know when they like or do not like something
Express their anger or frustration
Ask for help
Let you know when they are sick or hurt
Add any comments to the previous questions
Your answer
Leisure and Social Skills
Interact with other people
Share and take turns with others
Participate with family members in different activities
Prefers to be alone
Dislikes being in large groups of people
Shows limited interest in people, prefers objects
Shows limited interest in objects, prefers people
Add any comments regarding leisure and social skills
Your answer
Triggers (Please explain)
Your answer
Behavior they often exhibit
Kick
Hit
Scream
Cry
Bite
Grab
Pinch
Running
Verbally Agressive
Throws objects
Behavior the participant may exhibit
Stubborn or uncooperative, refuses to follow requests or instructions
Argues with others
Interrupts or intrudes conversations/activities of others
Excessive need to touch others or objects
Inappropriately seeking adult attention constantly
Gets upset or anxious when separated from familiar adults
Becomes overly upset or angry at situations
May use physical force to others when upset
Deliberately destroys things when upset
Makes up stories to avoid getting in trouble
Attempts to run away from situations
Gets upset to changes in daily routines or activities
Gets upset when told to stop their favourite activity
Gets upset if demands are not met immediately
Insists things are done in a specific way
is fearful of new situations, people or places
Has specific fears
Teases or annoys others intentionally
Bullies or threatens others
Does not protect their belongings
Takes food without permission
is excessively shy or withdrawn
is very sensitive, feelings are easily hurt
Lacks self confidence, needs constant reassurance and approval
Reacts badly when told NO or STOP
Runs, jumps or climbs excessively
Repeats specific words or topics over and over again
Puts non-edible foods in their mouth
Please specify or add comments to any behaviors mentioned above
Your answer
My loved one dislikes or gets upset when:
Your answer
My loved one is comforted or calms down when:
Your answer
Sensory ( They get upset or react strongly to)
Sounds
Temperature
Smells
Tastes
Being wet or dirty
Lighting
Movement
Add Comments to sensory
Your answer
Daily Living
Can hang up Jacket and put bag away upon arrival
Be careful around potential dangerous situations ( hot stove)
Uses kitchen appliances ( Microwave, toaster, stove top, kitchen knife)
Can make their own meals ( Cereal, sandwich, pour juice)
Uses public transportation on their own
Stays close to group or adult during community outing, does not wander away
Add any comments to daily living
Your answer
What are your loved ones strengths? (Something that makes them awesome!)
Your answer
What are your loved ones favourite activities?
Cooking/Baking
Arts/Crafts
Sports
Listening to music
Dancing
Yoga
Zumba
watching movies
Going for walks
Playing board games or doing puzzles
Add any comments to favourite activities
Your answer
What are your concerns for attending Livdayprogram?
Your answer
Why are you interested in joining Livdayprogram?
Meet new friends
Learn new skills
Community involvement
To have a routine
Stay busy throughout the day
Have fun!
How did you hear about Livdayprogram?
Found it on Google
Heard from a friend or family member
Saw an advertisement
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