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Participation Intake Form - Confidential

TOWN OF AURORA COMMUNITY SERVICES - INCLUSION
Please fill out this intake form if you have a participant attending a Town of Aurora Recreation Program who has a disability or unique need.

Personal Information

Participant Name:

Date of Birth

Language(s) at Home:

Parent/Guardian Name:

Relationship:

Parent/Guardian Primary Phone #:

Secondary Phone Number#

Email Address

Emergency Contact Information

Name:

Relationship to participant:

Primary Phone Number:

Email Address

Name:

Relationship to participant:

Primary Phone Number:

Email Address

Personal & Medical Information

Diagnosis (i.e. Asthma, Diabetes, Anaphylaxis) please list all diagnoses:

Medical Conditions:

Medication and/or Allergies (i.e. Epi-Pen):

Relevant Home Information:

Seizures (if applicable)

Does the participant have a seizure disorder?

Yes

Are seizures a common occurrence?

Yes

Are there any warning signs we should look out for?

Yes

What type of seizures?

Participant’s likes, hobbies and interests:

Participants dislikes:

Goal of this recreation opportunity for the participant: