All About Me 1Applicant2Medical Info3All About Me LinkedInThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formSubmission IDThis field is hidden when viewing the formDebugParticipant's InfoParticipant's Name* First Last Birth Date* MM slash DD slash YYYY Participant's Age*Parent's Email* Parent's Cell*Important InfoDoes the participant occasionally exhibit any of the following behaviors? Biting Grabbing Kicking Cursing Hitting Running Other None of the above Other behavior*What is your best method of handling the situation?*Please upload your child's IEP or BIP. If you do not have a IEP or BIP document to upload, please enter the overall plan in the field below. One is required. Please upload the participant's IEP or behavioral plan*Max. file size: 256 MB. Written Behavioral PlanThis field is hidden when viewing the formPlease upload the participant's BIPMax. file size: 256 MB. AllergiesDoes applicant have any allergies?* Yes No Please list allergies*This field is hidden when viewing the formApplicant is allergic to Hay Fever Poison Ivy/Oak 3. Insect Stings Food Penicillin Other Drugs Other This field is hidden when viewing the formFood Allergies* This field is hidden when viewing the formDrug Allergies* This field is hidden when viewing the formOther Allergies* This field is hidden when viewing the formNumber of Allergies CheckedDescribe reaction and treatment*Does applicant require an EpiPen?* Yes No If applicant requires an EpiPen, please list all instructions*EpiPen Authorization* Should the applicant have an allergic reaction, I give permission for staff to administer the EpiPen. Medications* I understand that Friendship Circle/LifeTown does not administer medication. This field is hidden when viewing the formMedical and Health InformationThis field is hidden when viewing the formDoes the applicant have a history of or is prone to any of the following Recent injury, illness or infectious disease Chronic or recurring illness Asthma Frequent Ear Infections Seizure Disorder or Convulsions Heart Defect/Disease Hypertension Bleeding/Clotting Disorders Diabetes Joint problems (knees, ankles) Fractures Frequent Headaches Head Injury Eating Disorder Diarrhea or constipation Frequent Stomachaches Other This field is hidden when viewing the formOther*This field is hidden when viewing the formPlease provide explanation for any checked itemsThis field is hidden when viewing the formPhysical Activities to be limited or restricted while at FC ProgramsThis field is hidden when viewing the formPlease provide any relevant medical or health information.*Medical AuthorizationMedical Authorization* I hereby give permission to the Friendship Circle-LifeTown administration to take whatever medical measures they deem necessary for my child in the event of a medical emergency. Emergency ContactEmergency Contact Name (other than parent)* First Last Emergency Cell* All About Me!Important information that my volunteer needs to know.CommunicationCommunication* I am verbal I am not verbal What is the best way to communicate with me?FoodFood* I can eat independently I need assistance eating Are there any food limitations or a special diet?* Yes No Please specify*BehaviorI Like*I don't like*If I need to be redirected, this is what helps meBathroomBathroom* I can go independently I need assistance I am not toilet trained Please Describe*SwimmingI can swim in shallow water* With assistance Without assistance Other Other:I can swim in deep water* With assistance Without assistance Other Other:Other Swim Info about meOther things you would like to tell us about the participantPhoto ConsentI allow my child’s photo to be included in a private album for parents only.* Yes No I allow my child’s photo and video to be used for any and all Friendship Circle publicity purposes (including website, social media, printed materials, etc.).* Yes No Δ
