Adaptive Diver Registry Form v2

COGNITIVE/ PSYCHOLOGICAL INFORMATION
Obtain the following information from the most reliable sources available: healthcare providers, parents, guardians, friends, and identify the source of information. If any of the following apply to the adaptive diver, please expand on them in the space provided below
1. Triggers: If the adaptive diver has any type of cognitive, psychological, or emotional impairment, please describe what, if anything, upsets or disturbs the individual or causes other emotional stress. (Enter N/A if non applicable to person)*
2. Tactile Sensitivity: Is the adaptive diver sensitive to anything touching them? If so, please describe. (Enter N/A if non applicable to person)*
3. What calming techniques are most effective should the adaptive diver become emotionally disturbed or upset? (e.g., diverting attention to favored topics, etc.) (Enter N/A if non applicable to person)*
4. Is there a health care provider, parent, guardian, friend, or other individual who knows how to address situations that may trigger emotional stress in the adaptive diver? If so, please provide their contact information.
Name
Relationship
Email
example@example.com
Phone Number
Please enter a valid phone number.

CURRENT MEDICATIONS / ALLERGIES
Please list any medications you are currently taking what they are for dose and administration regime
Do you have any allergies?*

YesNo
Please list allergies

VERIFICATION AND ACKNOWLEDGMENT
I, {name74} (adaptive diver), have reviewed the above registry information and verify that all the above information is true.
Print Full Name*
Date*

MonthDayYear
Date
Signature*

Clear
I, [Enter Full Name Below], the natural parent or legal guardian of the above identified adaptive diver, have reviewed the above registry information and verify that all the above information is true.
Print Full Name
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: