Name of Participant
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Pronouns (select all that apply)
If you selected other, please provide pronouns here:
Medicare Number
*
Photo consent given to Opal Family Services to take/post photos and/or videos of individual registered?
Please select which program you would like the individual to attend:
If you selected Kid's Club or Adult Program, please select the preferred days of the week for the individual to attend:
If you selected Breakfast Program, please select all preferred days of the week for the individual to attend:
If you selected Kid's Club, please select your preferred location:
Parent/Guardian #1
First Name
Last Name
Relationship
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone #1
(###)
###
####
Phone #2
(###)
###
####
Email
Parent/Guardian #2
First Name
Last Name
Relationship
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone #1
(###)
###
####
Phone #2
(###)
###
####
Email
Emergency Contact #1
First Name
Last Name
Relationship
Phone #1
(###)
###
####
Phone #2
(###)
###
####
Emergency Contact #2
First Name
Last Name
Relationship
Phone #1
(###)
###
####
Phone #2
(###)
###
####
Please describe any special needs that our staff should be aware of:
Current Medical Information:
Are there any other health/wellness needs we should be made aware of?
If you checked a box above, Please provide more information below (ex. Epilepsy: Specific causes)
Please list all medications that the individual registering is currently taking. Include name, condition it treats, dosage, administration, time, and any further instructions you feel necessary.
Please describe all allergies the person registering has. Include allergen name, type of reaction, and treatment (Epi-Pen/Benedryl)
Please check all applicable areas:
If you selected any of the above options, please indicate triggers:
Does the individual registered have any dietary concerns?
Please explain other dietary concerns:
1. Is additional assistance required for anything? For example: hygiene, verbal instructions, tying shoes, physical or emotional needs, etc.
2. Will the individual registered be using any special equipment and/or devices while attending programming?
3. How can we help the individual registered if they do not seem to understand what we are trying to communicate?
4. Does the individual registered have any favorite activities? (ex. strengths, abilities, preferences)
5. Does the individual registered have a support person? Will the support person be accompanying them? Why or why not? (They are more than welcome).
6. Does the individual registered have difficulty in new situations, noisy, or crowded places? Do they run away or become agitated? What is the best way to manage these situations?
7. Do you have any further guidance/suggestions for success?
Upon agreement, Opal Family Services can provide monthly invoicing. Please select the appropriate option below:
*
If you selected other, please explain below:
Please provide the name of your social worker (Family Support for Children with Disabilities or Child Protection) or Jordan's Principle Worker:
Phone (Social Worker/Jordan's Principle)
Email (Social Worker/Jordan's Principle)
