Participant's Name *

First Name

Last Name

Participant's Date of Birth *

MM

DD

YYYY

Cell Phone *

Provide for parent/guardian if participant is under age 18

(###)

###

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Please Check All that Apply *

Environmental and/or food allergies

Diagnosis or medical condition

Currently on medication(s)

Medications need to be taken during program hours

Need special accommodations

Challenges dealing with anger / frustration

Aggressive tendencies towards others when angry / frustrated

Self-harming tendencies

None of the above

Name of Parent (or Guardian)

First Name

Last Name

Parent's (or Guardian's) Cell

(###)

###

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Please Check All That Apply to Your Child *

History of biting, hitting, kicking, spitting on others

My child has been bullied in the past

My child is typically shy in a new setting

My child is usually loud and attention seeking in a new setting

None of the above