SUMMER OF FUN!!!
Participant Enrollment Form
Form must be completed in its entirety and submitted in order for the form to go through and be received by the Woolly Farms Foundation. If you do not receive a confirmation email, the form did not go through. Email eryn@mammothbuilt.com if you have any additional questions.
Name of Participant
*
First Name
Last Name
Name of Parent/Guardian
*
First Name
Last Name
Parent/Guardian Phone
*
Please enter a valid phone number.
Parent/Guardian Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alternate Contact Name
*
First Name
Last Name
Alternate Contact Phone Number
*
Please enter a valid phone number.
Do you have legal guardianship of participant?
*
Please Select
Yes
No
Please provide name and email address of participant's legal guardian. If participant is their own guardian, please enter their name and email address.
Does the participant live with you?
*
Please Select
Yes
No
If no to the above question, please explain.
Gender of Participant (for grant reporting only)
*
Please Select
Female
Male
Participant's Date of Birth
*
mm/dd/year
Disability
*
Autism
Cerebral Palsy
Down Syndrome
Other
Other Disabilities (Please describe your participant's other disabilities.)
Participant's Ethnicity (This field is for grant report only. You may select more than one.)
Caucasian
African American - Black
Hispanic - Latino
Asian
Native American
Mixed Race
Medicaid... Is your child Medicaid eligible? If you are on a waiting list, please select “yes.” (This is for grant reporting purposes only.)
*
Please Select
Yes
No
Earned Income... Is the participant’s income above or below $12,490? (This is for grant reporting purposes only.)
Please Select
Above
Below
Participant’s School Attending (if any)
Participant’s Current Employer (if any)
Participant’s Occupation or Employment Interest (if any)
Strengths… Please list the participant’s strengths, likes, dislikes, favorite activities, hobbies, sports, etc.
*
Communication… How does the participant communicate needs and wants?
*
Behaviors… List behaviors or fears we need to know about when participating in group activities.
*
Support… How we can best support participant when exhibiting behaviors.
*
Safety… Safety concerns for participant in group activities.
*
Aggression… Has participant had history of aggressive behaviors? Please explain.
*
Please type "NO" above if the participant does not have a history of aggressive behavior.
Wandering… Has participant had history of wandering off? Please explain.
*
Please type "NO" above if the participant does not have a history of wandering off.
Activities… What kinds of activities does the participant enjoy?
*
Does participant have a history of physical or verbal aggression, or outbursts of any kind?
*
Please Select
Yes
No
If "Yes" to above question, please explain.
Does participant have difficulty accepting correction or following directions?
*
Please Select
Yes
No
If "Yes" to above question, please explain.
Does participant have a history of destruction of property?
*
Please Select
Yes
No
If "Yes" to above question, please explain.
Does participant smoke or have a history of drug or alcohol abuse?
*
Please Select
Yes
No
If "Yes" to above question, please explain.
Has participant ever been charged or convicted of a crime?
*
Please Select
Yes
No
If "Yes" to above question, please explain.
Does the participant have a history of sexually inappropriate behavior?
*
Please Select
Yes
No
If "Yes" to above question, please explain.
Medical… List participant’s allergies/medical conditions.
*
Please type "NO" above if the participant does not have a allergies or medical conditions.
Other Info… Any other information which would be helpful to ensure participant’s enjoyment and safety.
Weekly Camps that your participant would like to attend. Please check all that they would like to attend.
*
Art Week… June 1-3, 9 am – 3 pm
Garden & Planting Week… June 15-17, 9 am – 3 pm
Water Week… June 29-July 1, 9 am – 3 pm
Animal Week… July 13-15, 9 am – 3 pm
Summer Olympics… July 27-29, 9 am – 3 pm
Water Olympics Week… August 10-12, 9 am – 3 pm
Respite Night… If you would like your participant to participate in a (or both) respite night(s), please select date(s). *Please note that there will be an extra fee to cover cost of meal and activity.
June 17, 3 pm - 9 pm
July 29, 3 pm - 9 pm
WAIVER… You must accept the Woolly Farms Foundation’s Waiver to be considered for participation. You can view the waiver by clicking the link below: https://secureservercdn.net/166.62.110.72/bpq.46b.myftpupload.com/wp-content/uploads/2021/05/liabilitywaiver2021.pdf
*
Accept
Special Notes
Submit
Should be Empty: