ILADD Participant Information Form
Participant Information
Name
First Name
Last Name
Preferred Name (if different)
Date of Birth
-
Month
-
Day
Year
Gender
Race/Ethnicity
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Confirm Email Address
*
example@example.com
Preferred Method of Communication
*
Text
Email
Medical and Support Information
Primary Disability or Support Need
*
Medical Conditions
*
Medications
*
Do you experience seizures?
*
Yes
No
If yes, please describe type and frequency and any seizure action plan:
Please list any allergies (food, medication, environmental):
*
Please describe any behaviors, risks, or safety concerns (such as elopement, aggression, anxiety triggers, or medical‑related risks) that ILADD should be aware of to ensure a safe and positive experience.
*
Insurance and Physician Information
Primary Insurance Company Name
*
Policy Number
*
Insurance Company Phone Number
*
Physician Name
*
Physician Phone Number
*
Secondary Insurance Company Name (optional)
Secondary Insurance Policy Number (optional)
Secondary Insurance Phone Number (optional)
Parent/Guardian/Support Staff Contacts
Primary Contact Name
*
First Name
Last Name
Relationship to Participant
*
Primary Contact Email
*
example@example.com
Confirm Primary Contact Email
*
example@example.com
Primary Contact Phone Number
*
Primary Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this person also an emergency contact?
*
Yes
No
Secondary Contact
Secondary Contact Name
*
First Name
Last Name
Relationship to Participant
*
Secondary Contact Email
*
example@example.com
Confirm Secondary Contact Email
*
example@example.com
Secondary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this person also an emergency contact?
*
Yes
No
Emergency Contacts
Emergency Contact #1
*
First Name
Last Name
Emergency Contact #1 Relationship to Participant
*
Emergency Contact #1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact #2
*
First Name
Last Name
Emergency Contact #2 Relationship to Participant
*
Emergency Contact #2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information
How did you hear about ILADD?
Are there any new programs you would like ILADD to offer?
Is there anything else you would like us to know?
Submit
Should be Empty: