Inclusive Ice Program Intake Form
Please answer the following questions to best serve you!
 
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Name of participant  *
Parent.  Full Name *
Parent. Phone Number  *
Parent 2.  Full Name 
Parent 2. Phone Number 
Parent Email.  *
Emergency Contact Name *
Phone number to contact in case of emergency *
How would you describe the participants on-ice experience  *

Type of Accommodation needed:

 *
Required
Does the participant have any neck or joint instability that need to be know for safety? *
If you answered yes to any of the above questions, please describe below. 
Any difficulty communicating or expressing? 
What form of communication do they use best? 

Personality & Behavior: Is the participant shy or eager to try new things? Describe how participant commonly engages with others off the ice


*
Likes & Dislikes: Please list strategies that typically help if the participant becomes escalated or shuts down. 
 *
How does the participant typically respond to an unfamiliar, or busy/loud environment? 
Does the participant have epilepsy or seizures?  *
If you answered yes to epilepsy or seizures, are there certain things which provoke them, what to look for, and/or actions needed? 
 Medications/Allergies: Does the participant take any medications or have allergies that TVF should be aware of?
*
Does the participant have an Epi-pen prescribed to them?  If yes, they must have it with them to participate in the program.  *
Are there any bathroom needs? 
Is the participant a risk of running away?  *

Additional Information: Please provide us with any other information you think may help our staff ensure a safe and successful class


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