All About Me 1Applicant2Medical Info3All About Me This field is hidden when viewing the formSubmission IDThis field is hidden when viewing the formDebugParticipant's InfoParticipant's Name* First Last Important InfoDoes the participant occasionally exhibit any of the following behaviors? Biting Grabbing Kicking Cursing Hitting Running Other Other behavior*What is your best method of handling the situation?*Other things you would like to tell us about the participant AllergiesDoes applicant have any allergies?* Yes No Applicant is allergic to Hay Fever Poison Ivy/Oak 3. Insect Stings Food Penicillin Other Drugs Other Food Allergies* Drug Allergies* Other Allergies* This field is hidden when viewing the formNumber of Allergies CheckedDescribe reaction and treatment*Does applicant require an EpiPen?* Yes No If applicant requires an EpiPen, please list all instructions*EpiPen Authorization* Should the applicant have an allergic reaction, I give permission for staff to administer the EpiPen. Medications* I understand that Friendship Circle/LifeTown does not administer medication. Medical and Health InformationPlease provide any relevant medical or health information.*Emergency ContactEmergency Contact Name (other than parent)* First Last Emergency Cell* All About Me!Important information that my volunteer needs to know.CommunicationCommunication* I am verbal I am not verbal What is the best way to communicate with me?FoodFood* I can eat independently I need assistance eating Are there any food limitations or a special diet?* Yes No Please specify*BehaviorI Like*I don't like*If I need to be redirected, this is what helps meBathroomBathroom* I can go independently I need assistance I am not toilet trained Please Describe*SwimmingI can swim in shallow water* With assistance Without assistance Other Other*I can swim in deep water** With assistance Without assistance Other Other*Other Swim Info about meThis field is hidden when viewing the formSwimming* I can swim in the shallow end I can swim in the deep end This field is hidden when viewing the formSwimming InstructionsPhoneThis field is for validation purposes and should be left unchanged.
