Download Fillable PDF Participant Name Address City Date Phone Postal Code Contact Name Address (if different from above) City Phone Phone Relationship Postal Code Email Weekly Theme Out ‘n’ Wild Your Inner Artist – SOLD OUT Adventures About – SOLD OUT Blast to the Past Born to Play – SOLD OUT Scenic Serenity – SOLD OUT Start Date July 7, 2025 July 14, 2025 July 21, 2025 August 11, 2025 August 18, 2025 August 25, 2025 End Date July 11, 2025 July 18, 2025 July 25, 2025 August 15, 2025 August 22, 2025 August 29, 2025 Fee $950 $950 $950 $950 $950 $950 Choice 950 950 950 950 950 950 Total: $0 Additional Information (Please fill out in full) Date of birth Age Transportation Arrangements DARTSHSROther # (if applicable) Please describe: Medical/Behavioural Information: 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 Alternate Contact Information: (Reachable During Activity) Name Phone Relationship Work/Mobile # Contact 2 Name Phone Relationship Work/Mobile #