Shabbaton - All About Me 1 Applicant2 Medical Info3 All About Me4 Parents Submission IDDebugParticipant's InfoParticipant's Name* First Last Birth Date*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Parent Email* Mom Cell:*Dad Cell:*Emergency Contact Name (other than parent)* First Last Emergency Cell* AllergiesDoes applicant have any allergies?*YesNoApplicant is allergic to Hay Fever Poison Ivy/Oak Insect Stings Food Penicillin Other Drugs Other Food Allergies* Drug Allergies* Other Allergies* Number of Allergies CheckedDescribe reaction and treatment*Does applicant require an EpiPen?*YesNoIf 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. MedicationsWill the applicant be taking medications during the Shabbaton?*YesNoPlease list all prescription and non‐prescription medications the applicant will need administered during the Shabbaton. Include the medication name, prescribing physician, physicians’ phone number, and the dosage instructions. When you check‐in, please provide all medications (in their original packaging that identifies the prescribing physician (if prescription drug)), the name of the medication, the dosage, and frequency of administration.Medications Medication Name Dosage Take at what times Reason for Taking Actions Edit Delete There are no Medications. Add Medication Maximum number of medications reached. Medication Authorization* I hereby authorize the staff to administer these medication(s) per physicians orders at FC programs. Can the applicant be administered over the counter pain medications?*YesNoApplicant may be given: Ibuprofen Acetaminophen Aspirin Benadryl Medical HistoryDoes 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 Other*Number of Medical History CheckedPlease provide explanation for any checked items*Physical Activities to be limited or restricted while at FC Programs All About Me!Important information that my volunteer needs to know.BehaviorDoes the participant occasionally exhibit any of the following behaviors? Biting Grabbing Kicking Cursing Hitting Other Other behavior*What is your best method of handling the situation?*If I need to be redirected, this is what helps meOther things you would like to tell us about the participantCommunicationCommunication*I am verbalI am not verbalWhat is the best way to communicate with me?FoodFood*I can eat independentlyI need assistance eatingAre there any food limitations or a special diet?*YesNoPlease specify*InterestsI Like*I don't like*BathroomBathroom*I can go independentlyI need assistanceI am not toilet trainedPlease Describe*BedtimeThe applicant usually goes to bed around this time:* : HH MM AM PM Is the applicant allowed to stay up later than their usual bedtime?* Yes No Is there anything else we should know about the applicant's bedtime routine? SignatureWho is filling out this form?*MotherFatherLegal GuardianName* First Last Signature*CommentsCommentsThis field is for validation purposes and should be left unchanged.