New Participant Registration Form_Our Place

Full Name *

First Name Last Name

Nickname

E-mail

example@example.com

Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Primary Phone *

Area Code Phone Number

Other Phone

Area Code Phone Number

Gender *

Date of Birth *

Date

Age *

Height *

Ex: 5'5''

HT *

Weight *

Name of Parent/Guardian (if applicable)

First Name Last Name

Relationship

E-mail

example@example.com

Phone

Area Code Phone Number

24 HR Emergency Contact *

First Name Last Name

Relationship

Primary Phone *

Area Code Phone Number

Other Phone

Area Code Phone Number

*Alternate Responsible Party

First Name Last Name

Relationship

Phone

Area Code Phone Number

*NOTE: This must be a person who WILL ACCEPT responsibility for you/your participant in case of an emergency where you or your emergency contact cannot be contacted. If parents, care-provider, or other person will be out of town while this person is in program, please attach information about where/when they can be contacted.

Name of individual filling out this form *

Date

Primary Phone *

Area Code Phone Number

E-mail

example@example.com

DISABILITY AND MEDICAL INFORMATION

Disability/Diagnosis (please be specific and list all that may affect participation): *

HEALTH INFORMATION
Please place a “check” in the appropriate box. Please answer the following questions completely.

Takes Medication *

YES (if yes, please fill out separate Medication Schedule Form attached.) NO

Has Arthritis *

YES NO

Drinks alcohol *

YES NO

If yes, describe:

Has Allergies *

YES NO

If yes, describe type, signs and treatment:

Has Asthma *

YES NO

If yes, describe medications used and frequency:

Has a history of seizures *

YES NO

If yes, describe type:

Frequency:

Date of Last Seizure and length:

Describe warning signs:

Describe how seizures are controlled:

Is diabetic *

YES NO

If yes, describe it is controlled:

Has high blood pressure *

YES NO

If yes, describe it is controlled:

Has a joint replacement *

YES NO

If yes, describe:

Has had surgery within past year *

YES NO

If yes, describe:

Has serious injury within past year *

YES NO

If yes, describe:

Has diet restrictions *

YES NO

If yes, describe:

Is visually impaired *

YES NO

If yes, describe:

Is hearing impaired *

YES NO

If yes, describe:

Is verbally impaired *

YES NO

If yes, describe:

Has heart condition *

YES NO

If yes, describe:

Smokes *

YES NO

Frequency

Requires bathroom assistance *

YES NO

If yes, provider/parent/guardian MUST attend Our Place classes with participant. Our Place staff DO NOT provide bathroom support for participants.

If yes, provider/parent/guardian MUST attend Our Place classes with participant. Our Place staff DO NOT provide bathroom support for participants.

Requires behavioral support *

YES NO

If yes, provider/parent/guardian MUST attend Our Place classes with participant. Our Place staff DO NOT provide provide 1:1 behavioral support for participants

If yes, provider/parent/guardian MUST attend Our Place classes with participant. Our Place staff DO NOT provide provide 1:1 behavioral support for participants

Other health information we should be aware of:

MOBILITY INFORMATION

Please select the appropriate answer. Please answer the following questions completely.

Uses device for mobility *

YES NO

If yes, mark all that apply:

Manual wheelchair walker power wheelchair cane at all times for long distances

If yes, can he/she transfer independently?

YES NO

Has prosthetic *

YES NO

Tires easily *

YES NO

Walks slowly *

YES NO

Is inactive *

YES NO

Has chronic Pain *

YES NO

Has chronic stiffness *

YES NO

Has difficulty Stretching *

YES NO

Describe strength and use of upper and lower extremities as it pertains to function, mobility and range of motion

BEHAVIORAL INFORMATION

To be completed by participant's primary caregiver or direct service professional. Please fill out next section completely and attach existing "Behavior Plan" if applicable.

Describe and list any unpredictable or inappropriate negative behaviors: (Example: aggression, property destruction, yelling, etc.) *

What causes these behaviors? (Example: fear, frustration, manipulation, hunger, stress, etc.) *

Are there any triggers we should be aware of? *

How are negative behaviors handles at home/school/work/program? *

Does Participant wander off or run away? *

If yes, where are they likely to go? *

What are triggers/causes? *

Self injurious behaviors we should be aware of? *

If yes, how are these behaviors handled? *

Other behavioral info we should be aware of: *

MEDICATION LIST

Select the appropriate answer. Does the participant take medications? *

YES (If yes, fill out Part 1) NO (If no, write "NONE" on Part 1)

Part 1: write name of Medication, dosage and purpose or reason for taking medication

	Name of Medication	Dosage	Purpose or reason for taking medication
1
2
3
4
5
6
7
8
9
10
11
12
13

Name of person filling out form *

Date *

Date

NUTRITIONAL PREPARATION, CLOTHING GUIDELINES, AND PROGRAM RULES

Please check each section to acknowledge you have read, undestand and consent.

Nutritional Preparation *

I understand

Ensure you are well nourished on the day of training.
Where possible, consume a high carbohydrate diet in the 24 hours prior to the training sessions (such as pasta,
potatoes, fruit, etc.) if this fits in your nutritional plan. If you have questions, please consult with your doctor.
You are strongly advised to have eaten some food in the four hours preceding training.
Ensure you are fully hydrated, particularly in hot conditions. Drink regularly in the days leading up to training,
particularly in the 12 hours prior to training.
Drink water regularly throughout your workout session. Continue to consume adequate fluids following exercise
to replace any fluids lost during training.

Clothing Guidelines *

I understand

It is recommended that you wear clean shorts or track pants, a cotton t-shirt or athletic/sports top, socks and nonslip athletic footwear with laces securely fastened.
No jeans or open toed shoes (i.e. sandals) can be worn to exercise.
Remove all restrictive jewelry, watches, bracelets or hanging earrings that may get caught in the equipment.
Bring a bottle of water and a small towel.

Our Place Wellness program rules *

I understand

Be kind and courteous to your fellow workout partners at all times
Drink water regularly throughout your workout session.
Eat at least 4 hours before exercising.
Wear clean workout clothes (no sandals or jeans).
Wipe down machines with disinfectant wipes after every use.
Do not answer/use cell phones in the facility.
Be patient and wait for your turn to use a machine.
If you are in pain, stop exercising and notify a staff member.
Wash or sanitize your hands before and after you exercise.
Shower and apply deodorant prior to exercising.
If you need help, ask staff for assistance.
Have fun!

I, the undersigned person, voluntarily sign this agreement, acknowledging I have read and understand the above information. My signature below also confirms that if I failed to understand anything in this document, I have sought and
received explanation of its meaning and significance to my complete satisfaction.

Participants Signature

Clear

Print Name

Date *

Date

Conservator's Signature (if applicable)

Clear

Print Name

Date

AGREEMENT OF RELEASE & WAIVER OF LIABILITY

*

I hereby agree to the following

1. That I am participating in the Our Place Wellness Center during which I will receive information and instruction about exercise and health. I recognize that the Our Place Wellness Center’s classes require physical exertion that
may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Our Place Wellness Center. I represent and warrant that I am physically fit and have no medical condition that would
prevent my full participation in the Our Place Wellness Center.

3. In consideration of being permitted to participate in the Our Place Wellness Center, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating
in the Our Place Wellness Center.

4. In further consideration of being permitted to participate in the classes offered by the Our Place Wellness Center, I knowingly, voluntarily and expressly waive any claim I may have against the instructor or The Arc of San Diego for injuries or damages that I may sustain as a result of participating in these classes.

5. I, my heirs, or legal representative of such forever release, waive, discharge and covenant not to sue The Arc of San Diego and its officers, directors, employees, agents, sponsors, in-kind donors or volunteers and any of its Our
Place Wellness Center’s instructors for any injury or death caused by their negligence or other acts.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

Participants Signature

Clear

Date

Conservator's Signature (if applicable)

Clear

Date

OUR PLACE WELLNESS CENTER CLASS REGISTRATION

Participants are registered for Our Place classes on a first come, first served basis. Our Place staff will take every effort to match each participant with their preferred class choices. However, some participants may not be enrolled in all top 3 class choices. All classes are 50 minutes in length.

**Please RANK each class in order of preference. 1 = Most Preferred Class; 9 = Least Preferred Class **

Adaptive Yoga - Group class which focuses on improving flexibility and mental strength through bodily postures. *

Adaptive Fitness - Group class which focuses on improving strength through weight lifting and cardiovascular exercise. *

Functional Fitness - Group class which focuses on improving functional movements and range of motion using “every day” items. *

Healthy Cooking - Group class which focuses on improving each participant’s nutritional plan through simple strategies and hands-on cooking classes. *

Art Therapy - Group class which focuses on improving overall well-being through artistic movements and art projects *

Music Therapy - Group class which focuses on improving overall well-being through the power of music and therapeutic movements. *

Adaptive Zumba/Dance Me Fit: Group class which focuses on improving cardiovascular strength through aerobic/dance movements to rhythmic music. *

Adaptive Taekwondo (NEW!) - Group class which focuses on improving flexibility, strength, and stamina through non-combative methods. *

Fit 4 Drums (NEW!)- Group class which focuses on improving the entire body through music and active,aerobic drumming. *

Shirt Size *

Location *

PUBLICITY RELEASE FORM

The Arc of San Diego is making a concentrated effort to promote the positive activities and successful work of our staff and consumers. This includes working with the local newspapers, radio,television stations and other media
publications.

Throughout the year, there will be opportunities for various participants to be interviewed and/or photographed as well as identified by name and program.

Please fill out the form below to inform us of your wishes regarding publicity

Please select one *

I give permission to be interviewed, identified, and/or photographed/filmed for use by The Arc of San Diego, including unlimited use for any and all purposes deemed appropriate by The Arc in printed, electronic,Internet, and other media without limitations or restrictions, and waive any claims of right to compensation orartistic control relating to the interviews, video footage, or pictures. I request that you do not interview or photograph me.

I have read and/or fully understand the above "Publicity Release" form. In signing this form, I certify that I am in agreement with its intent and purpose.

Participants Signature

Clear

Print Name

Date *

Date

Conservator's Signature (if applicable)

Clear

Print Name

Date *

Date

**Please note that this consent is updated annually and will be kept on file at The Arc of San Diego. You may revoke consent at any time by notifying The Arc of San Diego staff.

THE ARC OF SAN DIEGO OUR PLACE WELLNESS CENTER REGISTRATION FORM