Recreational Services Intake Form

Parent/Guardian Information

Please fill out this section of the form to completion. Use the down arrows to show additional form fields.
Primary Contact/Billing:

First NameLast Name

Disability/Diagnosis

Please fill out this section of the form to completion.
Primary:
Secondary:
Adaptive Equipment (check all that apply):

N/A - AmbulatoryCane/crutchesWalkerBrace/splintsOther
Special Instructions on equipment:

Communication
Please select the option below that best describes participant's communicative style?
Able to read?

YesNo
Able to write?

YesNo
Uses a communication device?

YesNo
If so, what type of device?
Does participant use visual supports (communication board, first/then, etc)? Please describe.

Medication/Medical
Please provide us with a list of all current medications being taken (including over-the-counter medication). If medication is given at the center, an additional form will need to be completed by the doctor. All prescription and over-the-counter medications that will be taken at the center must be in a RRS medication envelope. Each envelope must be labeled with the Participants name, date, time medication to be taken, and number of pills included. Please know that there is not a nurse on duty at the center. Participants will have to be able to self-administer medication once the medication envelope is given to the participant.

I give permission for the RRS program staff to give medication packet to be administered by participant during program.
First Name Last Name
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Restrictions per the doctor:

Seizure Information
Does your participant have seizures?

YesNo
If yes, a Seizure Questionnaire must be completed. Please notify our staff after you submit this form.
PLEASE KNOW THAT IF THERE ARE MEDICAL CONCERNS OF UNUSUAL CIRCUMSTANCES, 911 MAY BE CALLED.

Social
Please check all that apply

Participant initiates Social InteractionNeeds promptingAvoids Socialization

Releases
Please review the following releases below and check if you agree to the permissions.

If participant is over the age of 21, the participant has permission to consume alcohol during the program/trip? (2 drink maximum)I allow my picture or give permission for participant's picture to be used in marketing and on social media platforms like FacebookI am allowed to or give permission to my participant to attend outings scheduled with staff or RRSPermission for RRS staff to print participant's name, address, phone number in a phone book and/or roster to share with other participants?

Swim Information
Does the participant know how to swim?

YesNo
Does the participant use flotation devices? Note: RRS does NOT supply flotation devices.

YesNo
Does the participant use ear/nose plugs? Note: RRS does NOT supply plugs.

YesNo
Is the participant allowed to swim in deep water?

YesNo

Helpful Suggestions
Please share any information that would be helpful to work successfully with your participant. (Communication, fears, positive reinforcement suggestions, behavior management, and other helpful hints.)

Information for Grant Applications
Grants help us keep the cost of the program down. Please consider filling out the following questions. The information below is optional and will never be shared with any other person or organization.
Ethnicity

I do not wish to provide this informationHispanic or LatinoNon-Hispanic or Latino
Race

American Indian or Alaska NativeNative Hawaiian or other Pacific IslanderAsianWhiteBlack or African American
Household Size:
Ex: 4 members
Household Income:
Ex: $120,000

Client Information