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RECREATION PROGRAM PARTICIPATION FORM

 

Participants Name:      ______________________________________________________

Address:                      ______________________________________________________

______________________________________________________

Phone:                         _______________________________

Date of Birth:              _________________________

Parent/Guardian:         ______________________________________________________

Phone:                         ________________________________

Email address:             ______________________________________________________

Emergency Phone #'s:______________________________________________________

______________________________________________________

Special needs/challenges (elopement, communication, habits, etc.):

__________________________________________________________________________

__________________________________________________________________________

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MEDICAL INFORMATION -              Date:  ________________________

 

Allergies:       ____________________________________________________________

 

Limitations:   ____________________________________________________________

 

Medication:   ____________________________________________________________

 

Seizure History:      _______________________________________________________

 

Medicaid/Medicare #:        __________________________________________________

 

Doctor's Name & Number:_________________________________________________

 

I, __________________________________, hereby give permission to The Arc to initiate any/all emergency treatment necessary for the health and safety of ________________________________.  I will accept all fees incurred for emergency treatment.  I release The Arc from any liability for illness or injury while involved in the services of this agency.  *A copy of this form will be on site at all programs this person attends.*

*NOTE*:  During the year if there is a significant change in medical information, you must contact The Arc to request a new form so that medical information remains up-to-date.