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RECREATION PROGRAM PARTICIPATION FORM
Participants Name: ______________________________________________________
Address: ______________________________________________________
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Phone: _______________________________
Date of Birth: _________________________
Parent/Guardian: ______________________________________________________
Phone: ________________________________
Email address: ______________________________________________________
Emergency Phone #'s:______________________________________________________
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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.