Please identify and describe the participant:

            Name 
             Age 
             Sex Male Female

Date of Birth:  

-- mm/dd/yy

Nickname:

Contact information:

            Name 
  Street Address 
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal Code 
         Country 
      Work Phone 
      Home Phone 
      Cell Phone 

Primary Disability/Diagnosis:

Secondary Disability/Diagnosis:

What kind of supports does the participant need?

None
Initial orientation only
Assistance with fine motor skills (i.e.: cutting)
Uses an assistive device (wheelchair, cane, etc.)
Full time support
Interpreter

Comments:

What is the participant's primary means of communication?

speaks, understood by others         speaks, difficult to understand        non-verbal          sign language                      
gestures                             other (explain below)                

Comments:

Are personal services needed?

Yes No

Select behaviors that are a concern:

withdrawn/shy          easily discouraged     harms self/others      bites                
short attention span   manipulative           runs away              hyperactive          
other (explain below)  

Comments:

Does participant take medication during programs?

Yes No

If yes, please list medications and possible side effects:

Does participant have seizures?

Yes No

If yes, list type, duration, warning signs & desired first aid procedures:

List dietary restrictions/allergies/other medical conditions (diabetes, asthma) we should be aware of: