SPR-ParticipantForm-1

SPR-ParticipantForm-2

SPR-ParticipantForm-3

SPR-ParticipantForm-4


    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
    MedicaidMedicareOther

    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?
    YesNo


    Is the applicant able to self-administer his/her own medications?
    YesNoSome


    How many different meds does the applicant generally take?
    1-23-45 or more


    How many times per day does the applicant generally receive meds?
    1-23-45 or more


    Does the applicant generally take medications that require the monitoring of blood pressure, blood sugar or other bodily functions?
    YesNo


    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?
    YesNo


    If yes, what type?


    Is the applicant overly sensitive to the sun due to medication or other condition?
    YesNo


    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?
    YesNo


    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?
    YesNo


    Comments:


    Additional Comments regarding ADL Skills:



    This form was filled out by:


    Please re-enter your name as confirmation:



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    Due to the COVID-19 pandemic and despite great efforts from the staff, volunteers and our generous community of supporters, we have come to the disheartening realization that there is no viable way to continue with our travel and recreation programs.

    As of June 30, 2021 we will no longer offer our travel and recreation programs and will be focusing exclusively on our film distribution service Sproutflix (www.sproutflix.org).