Holiday Break Adaptive Day Program Informational Form
Participants Name
*
First Name
Last Name
Primary contact name and relationship to participant
*
Primary contact email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency contact name, relationship to participant and phone number
*
If there is a significant medical emergency, does The Legacy Ranch have approval to call emergency medical services if we cannot get ahold of emergency contact?
*
Please Select
Yes
No
This this participant have a diagosis?
Please Select
Yes
No
Primary Diagnosis
*
Secondary Diagnosis
*
Does this participant have any behavioral concerns that we need to be aware of? If yes, please describe.
*
Please explain what may trigger aggression in your participant if there are behavioral concerns
*
Allergies? If yes, please describe
*
The Legacy Ranch requires that participants use the restroom independently, but we are able to assist with handwashing and support navigating to the restroom.
*
Please Select
Yes, I understand
Please describe any specific sensory aversions and/or preferences
*
Does this participant need feeding instructions, restrictions, or special diet?
*
Participants method of communication
*
I understand and acknowledge that the program director and staff have the right to remove my participant from the program if they pose safety concerns for themselves, other participants, or staff. Please note- We will work with participants and their family to ensure that we set everyone up for success to avoid any removal from the program to ensure the safety of all parties.
*
Please Select
Yes
No, I would like to speak to someone to discuss further
Submit
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