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Care Recipient Registration Form
First name
*
Last name
*
Address
*
Email
*
Care Recipient's Name
*
Care Recipient's Date of Birth
*
Month
Month
Day
Year
Care Recipient's Gender
*
Care Recipient Lives With
*
Address (If Different Than Above)
Father's Name
*
Father's Phone Number
*
Mother's Name
*
Mother's Phone Number
*
Alternate Emergency Contact
*
Alternate Emergency Contact Phone Number
*
What is the care recipient's diagnosis?
*
What health concerns should we be aware of?
*
Does the care recipient have seizures?
*
Please describe the care recipient's allergies, if any.
*
Under what circumstances would you like to be notified during care group?
Vision
*
Hearing
*
Motor
*
Adaptive Equipment Used
*
What sensory needs does the care recipient have?
*
Does the care recipient have any special toileting or self-care needs?
*
Is there anything that upsets the care recipient?
*
Are there activities that help calm the care recipient?
*
What behavior and/or learning strategies work best for the care recipient?
*
Does your family attend church in the community?
*
If so, which one?
Submit
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