Application
Personal Snapshot❤️
TFC Activity Photo Consent
Photos are used only to support participation during Friends Club activities (for example, ice breakers and visual supports) and will never be used for marketing or promotional purposes.
Participant Photo
Independence and Daily Living Skills
1- Requires Significant Support; 2- Requires Frequent Support; 3- Requires Occasional Support; 4- Mostly Independent; 5- Consistently Independent
Toileting
*
Requires Significant Support
1
2
3
4
Consistently Independent
5
1 is Requires Significant Support, 5 is Consistently Independent
How independently does participant use the restroom during community outings?
Independently recognizes when they need to use the restroom
Independently manages clothing
Independently completes hygiene
Requires verbal reminders
Requires physical/companion assistance
Additional Notes:
Mobility
*
Requires Significant Support
1
2
3
4
Consistently Independent
5
1 is Requires Significant Support, 5 is Consistently Independent
How independently can the participant navigate their community safely in a group setting?
Can stay with a group
Requires adult support to transition with group
Requires physical mobility support (wheelchair, orthotics or braces, etc.)
Stops appropriately at crosswalks or intersections
May wander or elope if not closely supervised
Benefits from visual schedules or transition reminders
Additional Notes:
Eating
*
Requires Significant Support
1
2
3
4
Consistently Independent
5
1 is Requires Significant Support, 5 is Consistently Independent
How independently does the participant eat meals and snacks during community outings?
Uses adaptive utensils
Food needs to be cut
Reminders to eat
Supervision due to choking concerns
Food allergies
Food sensitivities
Additional Notes:
Community Participation
*Answers Required for this section
Can safely participate in community outings?
*
Yes
No
With Adult Support/ Reminders
Can follow group expectations and safety guidelines in public settings?
*
Yes
No
With Adult Support/ Reminders
Can remain with the group during outings?
*
Yes
No
With Adult Support/ Reminders
Can handle changes in routine, unexpected situations, or busy environments?
*
Yes
No
With Adult Support/ Reminders
Community Safety Concerns
Communication and Social Participation
1- Requires Significant Support; 2- Requires Frequent Support; 3- Requires Occasional Support; 4- Mostly Independent; 5- Consistently Independent *Answers Required for this section
Communication with Unfamiliar People
*
Requires Significant Support
1
2
3
4
Consistently Independent
5
1 is Requires Significant Support, 5 is Consistently Independent
Additional Notes:
Following Directions
*
Requires Significant Support
1
2
3
4
Consistently Independent
5
1 is Requires Significant Support, 5 is Consistently Independent
Additional Notes:
Joining Group Activities
*
Requires Significant Support
1
2
3
4
Consistently Independent
5
1 is Requires Significant Support, 5 is Consistently Independent
Additional Notes:
Flexibility
*
Requires Significant Support
1
2
3
4
Consistently Independent
5
1 is Requires Significant Support, 5 is Consistently Independent
Additional Notes:
Emotional Regulation
*
Requires Significant Support
1
2
3
4
Consistently Independent
5
1 is Requires Significant Support, 5 is Consistently Independent
Additional Notes:
Making Friends
*
Requires Significant Support
1
2
3
4
Consistently Independent
5
1 is Requires Significant Support, 5 is Consistently Independent
Additional Notes:
What strategies or supports help the participant feel most successful in social situations?
Accommodations & Supports
This information allows us to provide appropriate supports in groups and community settings while encouraging independence and ensuring a positive experience for all participants.
Which supports will help the participant to be most successful?
Verbal reminders
Visual schedule
Written checklist
First/Then reminders
Choices between activities
Quiet break when needed
Modeling by an adult
Modeling by a peer
Positive encouragement
Additional processing/wait time
Are there sensory supports that will help the participant be most successful?
Frequent movement breaks
Sunglasses
Quiet space
Fidget or comfort item
Headphones
Other
Additional Notes:
What are some goals you have in mind for the participant to become more independent with when participating in The Friends Club?
*
Starting conversations
Making friends
Community skills (ordering food, making purchases)
Community safety
Following group plans
Self- advocacy
Trying new activities
Building confidence
Self- regulation
Additional Notes:
Supporting Paperwork (Goals Plan, IEP, Behavior Plan)
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Toileting Support
Participant Information
Participant Name
*
First and Last
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant Age
*
Current Program Enrollment Information
Please provide any information you might find useful about the participant's current daily routine.
Companion Information
To provide the most successful start to The Friends Club, participants will attend with a familiar adult or companion. This allows participants to build confidence while helping our staff get to know each individual's level of independence. During this introductory period (approx 4 sessions), our staff will assess each participant's support needs in order to make future recommendations for companion involvement.
Companion Name (if currently unknown leave blank but required for Registration)
First Name
Last Name
Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent / Guardian Information
Primary Contact Name
*
Relationship to Participant
*
Please Select
Parent
Guardian
Grandparent
Step-parent
Foster Parent
Other
Parent/ Guardian Email
*
Please Select
Parent
Guardian
Grandparent
Step-parent
Foster Parent
Other
Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact Name
Secondary Relationship to Participant
Please Select
Parent
Guardian
Grandparent
Step-parent
Foster Parent
Other
Secondary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Emergency Contact
*
Medical Information
Allergies
*
Is an EpiPen required?
Yes
No
Dietary Restrictions
Medical Conditions/ Other Health Concerns To Be Aware Of
Will the participant require medication during Friends Club sessions? (approx 3-5pm)
No
Yes
If yes, caregiver will administer medication
If yes, participant can administer their own medication
If yes, participant needs reminder of when to take medication
If yes, participant does not need reminder of when to take medication
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