Rising Lights Project - Adults Intake Form

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This intake form is required for all adults involved with Rising Lights Project

Your Email *

Student's Email

Today's Date *

YYYY

Student's Full Name *

Student's- Date of Birth *

YYYY

Home Address *

Diagnosis: Please explain his/her needs and supports *

Toileting Needs: independent OR needs support (please explain) *

Please list any behavior concerns *

Allergies and/or dietary restrictions *

Current Daily Medication: (please include name, dosage and use) *

History of seizures? *

Yes

Maybe

If yes, date if the most seizures?

YYYY

If yes, describe type and emergency protocols in the events of a seizure.

Personal Interests *

Personal Dislikes *

Parent's First and Last Name *

Parent's Cell Number *

Emergency Contact Information *

Anything else you would like us to know? *

Are you okay that RLP uses pictures to post on social media and our website to demonstrate the work we are doing? *

Yes

Maybe

*For garden group members only*

In the event your child comes into contact with poison ivy or a bee sting, may we administer Benadryl?

Yes

Other:

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