NYC Program: Sprout Participant Registration Form

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Applicant Information

First Name*

Address Line 1*

City*

Zip Code*

Date of Birth*

E-Mail:

Agency Information

Agency

Address Line 1

City

Zip Code

Phone

Emergency Contact

Name*

Day Phone*

Parent/Guardian Information

Name of Parent or Guardian

Address Line 1

City

Zip Code

Phone

Please select the living arrangement the applicant is currently in:

Medical Information

Medical Insurance
 Medicaid Medicare Other

If Other:

Policy Number:

Medication Information

We understand that medications often change over the course of time and can sometimes change the day before a trip leaves. However, please answer the following questions to give us an idea of the attention to medications that the applicant will require. Exact medication information including meds, times and dosage must be presented to trip staff at the start of each trip.

Does the applicant generally take medications?
 Yes No

Is the applicant able to self-administer his/her own medications?
 Yes No Some

How many different meds does the applicant generally take?
 1-2 3-4 5 or more

How many times per day does the applicant generally receive meds?
 1-2 3-4 5 or more

Does the applicant generally take medications that require the monitoring of blood pressure, blood sugar or other bodily functions?
 Yes No

If yes, please describe what needs to be monitored:

Please list any known allergies:

Does the applicant have seizures?
[radio* seizures "Yes " "No"]

If yes, please list type and general frequency:

Does the applicant have hepatitis?
 Yes No

If yes, what type?

Is the applicant overly sensitive to the sun due to medication or other condition?
 Yes No

Please comment on any physical limitations the applicant may have:

Please list any dietary restrictions:

At times during our trips, we allow our participants to have one alcoholic beverage with dinner. Is the applicant allowed to have an alcoholic beverage?
 Yes No

Please comment on any additional medical information that we should know about:

Behavioral Profile

Please describe the applicant's general behavior and social abilities:

Please describe the applicant's communication skills (if applicant is non-verbal, to what extent can s/he maker her/his needs known?):

What are some of the difficulties that the applicant may encounter during the trip?

Please comment on the applicant's ability to stay with the group. (Does the applicant have a tendency to wander? Is the applicant easily distracted by other sights when moving within a grip? Will the applicant walk away from a group on his/her own?)

Additional Comments:

ADL Skills

Please provide any information related to the completion of the task in each category.

Using Toilet

Comments:

Bathing/Showering

Comments:

Washing Hair

Comments:

Brushing Teeth

Comments:

Shaving

Comments:

Using Deodorant

Comments:

Dressing/Undressing

Comments:

Separating Dirty Clothes

Comments:

Is s/he able to use public transportation independently?
 Yes No

Comments:

Additional Comments regarding ADL Skills:

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Please re-enter your name as confirmation:

Please leave this field empty.

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