Participant Name

Address

City

Date

Phone

Postal Code

Contact Name

Address (if different from above)

City

Phone

Phone

Relationship

Postal Code

Email

Additional Information

(Please fill out in full)

Date of birth

Age

Transportation Arrangements

DARTSHSROther

# (if applicable)

Please describe:

Does the client have seizures?
YesNo
If yes, please describe:

Does the client require behavioural re‐direction?
YesNo
If yes, please list strategies that would be helpful:

Is there a Behaviour Support Plan in place? (if yes please attach)
YesNo
Attach Document

We are unable to administer medication or support any medical care needs in these supported leisure programs. Are there any other needs you want us to know about (e.g. asthma, hearing, sight)?

Allergy Information

Do you have life threatening allergies?
YesNo

Do you carry an Epipen?
YesNo

Identify

Any other allergies?

Mobility Information

Mobility aids?
WheelchairWalkerCane(s)Staff GuideN/A

Mobility/ transfer support?
YesNo
If yes please describe

Support for personal hygiene/ toileting?
YesNo
If yes please explain

Assistance with eating and drinking?
YesNo
If yes please explain

Does the client require behavioural re‐direction?
YesNo
If yes, please list strategies that would be helpful:

Communication Information

Preferred communication
VerbalNon-verbalGestures/ Sign LanguageCommunication system

I give permission to Community Living Hamilton to take my photograph for identifications purposes and for any promotional purpose
YesNo

Name

Phone

Relationship

Work/Mobile #

Contact 2

Name

Phone

Relationship

Work/Mobile #