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 (Optional)
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?
Is there anything else you would like us to know?
Submit
Should be Empty: