Therapeutic Recreation Membership Form

Therapeutic Recreation Membership Form

Complete the Therapeutic Recreation (TR) Membership Form to become a TR participant in the St. Petersburg Parks & Recreation Department's TR Program at Azalea Recreation Center.
Please check the appropriate choice:*

New TR program participantReturning TR program participant
Participant's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

FemaleMaleOther
School*
Type N/A if not applicable.
Parent/Guardian's Name:*

First NameLast Name
Parent/Guardian's Relationship*
Relationship
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Medical Information
Primary Diagnosis*
Secondary Diagnosis*
Type N/A if not applicable.
Medication*

YesNo
If yes, what medication?*

Type N/A if not applicable.0/100
Allergies*

YesNo
If yes, what allergies?*

Type N/A if not applicable.0/100
Communication
Verbal*

YesNo
Verbal - Check all options that apply to the participant:

Easy to understandHard to understandSoft spoken
Nonverbal - Check all options that apply to the participant:

Makes soundsMumblesGesturesFacial expressionsWritesCommunication boardSigns (ASL)Makes eye contact
Notes:*

Type N/A if not applicable.0/100
Vision
Visually Impaired*

YesNo
Visual Impairments*

Left eyeRight eyeBoth eyesNot Applicable
Visual Impairments - Check all options that apply to the participant:

NearsightedFarsightedCataractsSigmatism
Glasses/Contacts*

YesNo
Blind*

YesNo
Notes:*

Type N/A if not applicable.0/100
Hearing
Hearing Impaired*

YesNo
Hearing Impairments*

Left earRight earBoth earsNot Applicable
Hearing Impairments - Check all options that apply to the participant:

SlightMildModerateSevereProfoundHearing Aids
Notes:*

Type N/A if not applicable.0/100
Fine/Gross Motor Impairments

Check the options that apply to the participant:
Left Hand*

YesNoPartial
Right Hand*

YesNoPartial
Left Upper Body*

YesNoPartial
Right Upper Body*

YesNoPartial
Left Lower Body*

YesNoPartial
Right Lower Body*

YesNoPartial
Hand-Eye Coordination*

YesNoPartial
Notes:*

Type N/A if not applicable.0/100
Mobility
Mobility Impairments:*

YesNo
Mobility Impairments - Check all options that apply to the participant:*

Holds head upCrawlsSits independantlySits with assistanceStands indpendantlyStands with assistanceWalks independantlyWalks with assistanceRunsClimbs stairs
Uses Adaptive Equipment:*

YesNo
Adaptive Equipment - Check all options that apply to the participant:*

Power WheelchairManual WheelchairWalkerCane
Notes:*

Type N/A if not applicable.0/100
Eating/Drinking
Eating

IndependentNeeds assistance
Eating - Check all options that apply to the participant:*

Needs food cutHoards foodTakes other's food
Drinking

IndependentNeeds assistance
Drinking - Check all options that apply to the participant:*

Needs a strawHoards drinksTakes other's drinks
Notes:*

Type N/A if not applicable.0/100
Personal Hygiene & Toileting
Personal Hygiene

IndependentNeeds assistance
Personal Hygiene - Check all options that apply to the participant:*

Needs supervisionAssistance transferringAssistance with clothingAssistance washing hands
Toileting

IndependentNeeds assistance
Toileting - Check all options that apply to the participant:*

Needs supervisionUses hand held urinalAssistance transferringAssistance with clothingBladder accidentsBowel accidentsAssistance with menstral products
Notes:*

Type N/A if not applicable.0/100
Behavior/Emotional
Behavior/Emotional - Check all options that apply to the participant:*

IrritableFrustrated easilyTearfulSensitive easilyPhysically aggressiveNot Applicable
What causes the particpant to become physically aggressive?*

0/100
What types of behaviors occurs when physically aggressive?*

0/100
What techniques are sucessful in de-escalating the physical aggression?*

0/100
What is the duration of the behavior when physically aggressive?*
Type N/A if not applicable.
Please describe any other behavior(s) the participant may exhibit:*

Type N/A if not applicable.0/100
Please describe how you handle a disciplinary problem:*

Type N/A if not applicable.0/100
Additional Information
Has participant been successful when the staffing ratio is 1 to 4 youth, 1 to 5 teen, or 1 to 6 adult.*

YesNo
Other Services/Therapies - Check all options that apply to the participant:*

SpeechOccupationalPhysicalPsychologicalApplied Behavioral Analysis (ABA)Not Applicable
Please suggest one goal you would like the participant to work toward:*

Type N/A if not applicable.0/100
Please provide any information about the participant you think would be beneficial for our staff:*

Type N/A if not applicable.0/100
Would you like to add an Accommodation Request Form to this membership form?*

YesNo
Accommodation Request Form
Please upload a completed reasonal accomodation form here.

Cancelof
Your signature below indicates that the information on this form is complete and accurate and if found to be inaccurate could result in dismissal from the TR Programs. I hereby grant permission for City staff to assess the participant, talk with school personnel, and review their IEP/BIP to determine readiness to partcipate.
Signature

Clear
Name

First NameLast Name
Should be Empty:

Therapeutic Recreation Membership Form

Medical Information

Communication

Vision

Hearing

Fine/Gross Motor Impairments

Mobility

Eating/Drinking

Personal Hygiene & Toileting

Behavior/Emotional

Additional Information