2024 Health Status Form

Participant Name*

First NameLast Name

Name of Person Completing the form*

First NameLast Name

1st Medical Emergency Contact*

First NameLast Name

Phone Number of 1st Medical Emergency Contact

Please enter a valid phone number.

2nd Medical Emergency Contact*

First NameLast Name

Phone Number of 2nd Medical Emergency Contact

Please enter a valid phone number.

Email*

example@example.com

Is participant wheelchair dependent?*

NoYes

Does the participant have special communication needs?*

NoYes, Explain below

Please explain any special communication supports needed

Does the participant have any sensory issues? (check all that apply)*

Yes, sensitive to loud noisesYes, sensitive to flickering and/or strobe lightsYes, sensitive to bright lightsYes, sensitive to smellsYes, sensitive to touchYes, sensitive to "scratchy" or other textures against skinOther sensory issues (please explain below)No sensory issues

If you chose "other sensory issues," please explain

Please list all relevant allergies. (type "none" if no allergies)*

Please list all relevant health concerns. (type "none" if no health concerns)*

Please list all diagnoses that emergency providers would need to be aware of. (type "none" if no diagnoses)*

Please list all medications that emergency providers would need to be aware of. (type "none" if no medications to list)*

List all emergency protocols we should be aware of, such as advanced medical directives; do not transport; or if we cannot reach the emergency contacts:*

Physician Name*

Clinic Name

Physician Phone Number*

Please enter a valid phone number.

Signature - By signing below, the person filling out this form attests that the information provided is true, accurate and complete to the best of his/her knowledge*

To complete registration, the following forms are needed:

Fill out once for 2024:

2024 In-Person Intake Form
2024 Health Status Form
2024 Health Liability Release Waiver
2024 In-Person Code of Conduct
2024 Participant Consent Form

Fill out each term:

The appropriate term's Registration Form