Legacy Project Application
Email address *
CLIENT INFORMATION
First & Last Name *
Your answer
Cell Phone *
Your answer
Alternative Phone Number
Your answer
Street Address *
Your answer
City, State & Zip Code *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Height *
Your answer
Weight *
Your answer
Medical Diagnosis *
If you noted 'other' above, please specify diagnosis here:
Your answer
Date of Injury or Onset *
MM
/
DD
/
YYYY
If spinal cord injury, what is your level of injury?
Your answer
Check ALL that apply to you: *
Required
Do you have any of the following: *
Required
Type of wheelchair, if applicable: *
List assistive devices you use in your everyday life, if applicable:
Your answer
EMERGENCY CONTACT
Contact Person (First & Last Name) *
Your answer
Contact Phone Number *
Your answer
Relationship to Client *
Your answer
GOALS & QUALITY OF LIFE
What are your goals over the 12 week program? *
Your answer
Why should REACT select you over other applicants? *
Your answer
What are you favorite hobbies? *
Your answer
Do you drive? *
Do you work or are you in school? *
If you answered yes, please describe your work or school:
Your answer
Rate your level of stress at home *
no stress
extreme stress
What other adaptive / therapy programs have you participated in? *
Your answer
What time do you go to bed at night? *
Time
:
What time do you wake up in the morning? *
Time
:
How did you hear about REACT? *
If other, please explain. For referral, please let us know who referred you:
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms