Qualtrics Survey | Qualtrics Experience Management

Program Participant:

Last Name:

First Name:

Date of Birth:

Grade Level:

Diagnosis:

Home Address:

Parent or Guardian:

Last Name:

First Name:

Work/Cell phone:

Email Address:

Home Address (If different from above):

What is the best way to reach you?

Emergency Contacts:

(1) Name:

Relationship to child?

Work/Cell phone:

Home phone:

(2) Name:

Relationship to child?

Work/Cell phone:

Home phone:

Health Information:

Participant's Physician:

Phone:

Clinic:

Address:

Special medical needs or concerns:

Allergies:

Other information:

I authorize emergency medical treatment for my child, ________________, in the event that a parent/guardian or emergency contact cannot be reached in a timely manner.

Sign Here

clear

Printed Name:

Diagnosis

Is the client diagnosed with a disability? If yes, what disability?

Does the client receive other outside therapies? Please list below.