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
- Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Parent/Guardian #1 Email:
  example@example.com
- Parent/Guardian #1 Address (if different above):
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Employer:
- Position:
- Employer's Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Parent/Guardian #2 Email:
  example@example.com
- Parent/Guardian #2 Address (if different above):
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Employer:
- Position:
- Employer's Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Emergency Contact:
- Relationship:
- Home Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Cell Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.

Please select the option below that best describes participant's communicative style?
Able to read?
Able to write?
Uses a communication device?
If so, what type of device?
Does participant use visual supports (communication board, first/then, etc)? Please describe.

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
Restrictions per the doctor:

Does your participant have seizures?
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.

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

Does the participant know how to swim?
Does the participant use flotation devices? Note: RRS does NOT supply flotation devices.
Does the participant use ear/nose plugs? Note: RRS does NOT supply plugs.
Is the participant allowed to swim in deep water?

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.)

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
Race
Household Size:
Ex: 4 members
Household Income:
Ex: $120,000

Client Information