Participant Name

Phone

D.O.B.

Full Address

Transportation Arrangements

DARTSHSROther

# (if applicable)

Please describe:

Contact Information

Contact Name

Phone

Full Address (if different from above)

Relationship

Email

Billing Name/Address (if different from above)

Activity

Start Date

End Date

Fee

I give permission to Community Living Hamilton to take payment from CLH Administered Passport Funding.
YesNo

Signature

Name

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)?

Do you have life threatening allergies?
YesNo

Do you carry an Epipen?
YesNo

Identify:

Any other allergies:

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

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 #