Community Inclusion Program
Please complete this form to register for the Community Inclusion Program at Pyramid House Foundation. If you have any questions or need help filling out, contact us at (908) 845-8956 or info@pyramidhousefoundation.org
Participant's Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
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Phone Number
*
Email Address
Emergency Contact Name
*
First Name
Last Name
Relation to Participant
*
Emergency Contact Phone Number
*
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DDD Information
Please provide details so we can coordinate billing and communicate with the support coordinator.
DDD ID Number
Support Coordinator's Name
*
First Name
Last Name
Support Coordinator Agency
*
Support Coordinator Phone
*
NJCAT Tier Level
*
Mobility Status
Let us know the participant's mobility status so we can plan activities that are safe and accessible.
Mobility Status
*
Ambulatory (walks independently)
Ambulatory with assistance (cane, walker or hand-holding)
Wheelchair user (Note: we currently cannot accommodate wheelchair user.)
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Activity Registration
Select the activity you'd like to register for and share your transportation needs. This information helps us reserve a spot and arrange transportation if needed.
Activity Name
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Date of Activity
*
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Month
-
Day
Year
Date
Time of Activity
*
Hour Minutes
AM
PM
AM/PM Option
Activity Cost
*
If needs transport, provide pick up address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Medical Information
We need to know about any medical conditions, allergies, or medications to ensure the participant's health and safety during activity.
Does the participant have any medical conditions staff should be aware of? If Yes, please describe.
Allergies (food, medications, environmental)
Current medications (that may be administered during activity)
Emergency Medications (Please attach physician's orders)
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Behavioral Support Information
Sharing this information helps staff understand the participant's needs, respond appropriately, and provide a positive experience during activities.
Does the participant have a Positive Behavior Support Plan (PBSP)? If Yes, please attach a copy or have Support Coordinator email to info@pyramidhousefoundation.org
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Known behavioral triggers
Effective De-escalation strategies
Communication Style
Please Select
Verbal
Limited Verbal
Non Verbal
Uses AAC Device
Dietary Restrictions
Please let us know of any dietary restrictions so we can provide suitable snacks or meals during activities.
Dietary Restrictions
No Dietary Resctrictions
Dairy-free
Vegetarian
Vegan
Pescetarian
Halal
Kosher
Gluten Free
Other
Support Needs
Indicate the areas where the participant requires additional assistant to help us prepare appropriates support during activities.
Check all areas where participant needs staff support
Toileting
Eating/Feeding
Communication Support
Behavioral Redirection
Medication Administration
Mobility Assistance
Hand-over hand guidance
Sensory Accommodations
Preferences and Interests
Tell us about the participant's likes and dislikes to help us plan engaging activities and avoid challenges.
What does the participant enjoy?
What does the participant dislike or find challenging?
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Consent and Releases
Please review and confirm your consent for medical emergencies, photo/video use and participation guidelines.
Medical Emergency Authorization
*
I authorize Pyramid House Foundation staff to seek emergency medical treatment for the above-named participant if I cannot be reached. I understand that I will be responsible for any medical expenses incurred.
Photo/Video Release
*
Yes, I grant permission for Pyramid House Foundation to photograph/video my family member for program documentation, marketing, and social media.
No, I do not grant permission for photos/videos.
Activity Participation Agreement
Please review the following agreement before submitting this form. By signing below, you acknowledge that you have read, understood, and agreed to the terms listed.
I understand that: 1. Participant must be ambulatory (able to walk with or without assistance) 2. Activities involve community outings and physical activities 3. Staff will supervise but cannot guarantee participant safety 100% 4. I will provide accurate medical and behavioral information 5. I will pick up participant on time or arrange alternative transportation 6. Behavioral issues that endanger others may result in activity termination and pick-up request 7. Pyramid House Foundation reserves the right to deny registration if unable to safely accommodate participant's needs.
*
I have read and agree to the Activity Participation Agreement.
Signature
Payment Information
Provide payment details for activities that have fees or confirm authorization to bill DDD if applicable.
Activity Fee
If DDD billing
I authorize Pyramid House Foundation to bill DDD for Community Inclusion services and agree to pay all activity fees associated with the activities I sign up for.
Signature
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