Participant's Name * First Name Last Name Participant's Date of Birth * Participant's Diagnosis Participant Information Secondary Disability Diagnosis Participant's Information School/Workshop/Employer * Parent/Guardian Name * First Name Last Name Parent/ Guardian Phone * (###) ### #### Second Parent/Guardian Phone (###) ### #### Address * Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Email * Doctor's Name * First Name Last Name Doctor's Phone * (###) ### #### Health Information: Ambulatory * Yes No Verbal * Yes No Seisures * Yes No Communicable Disease * Yes No Dietary Restrictions * Special Equipment * Communication Method * Exhibited Behavior Behavior Management/Redirection List of Medications List any allergies Additional information about participant: T-shirt Size * Select from dropdown Adult S Adult M Adult L Adult XL Adult 2X Adult 3X Adult 4X Programs Please select programs you are interested in IGNITE Club Connect T.H.R.I.V.E. Abilities on Stage IGNITE Cooking Club WARRIOR Adaptive Training Thank you! Enrollment Form
