Participant Application Form

PARTICIPANT APPLICATION: The following information must be completed and signed by a parent or guardian in order for the child to be considered for any Special Reach program.

Date of Application

Participant's Name

Date of Birth

Sex

Male Female

Race

Age

Height

Weight

Participant's Address

Diagnosis

Name of School

School Phone

School District

Grade

Please tell us your child's classroom environment.

Full Inclusion Mostly Self Contained A Little Bit of Both

How did you hear about us?

Allergies

List current medications and any side effects that might affect your child during the program. *Note: Medications will not be administered during the program.

Are there any limitations and/or physical restrictions we need to know about your child?

List any dietary restrictions and/or food allergies

Participant’s Physician

Phone

It is my understanding that if there are any changes to the information above I will inform the Special Reach staff as soon as possible in writing.

Digital signature

Clear

Date

Immunization Records: My child/children’s immunization records and tuberculosis test record are current. Please provide us with a copy.

Digital signature

Clear

Date

Participant Profile

To ensure the most positive experience, please help us by completing the following information.

What is your child’s primary mode of communication?

Verbal‎ Signing‎ Pictures‎

Does your child have a different mode of communication? If so, please explain.

Briefly describe your child's current level of social development

Does your child follow verbal directions?

Yes No Sometimes

Does your child swear or use obscene language?

Frequently‎ Sometimes‎ Never‎

Specify any special attention your child needs due to sensory challenges?
Indicate "None" if applicable.

Does your child communicate the need to use the restroom?

Yes‎ No‎ sometimes‎ Uses Diapers‎

Does your child need frequent reminders to use the restroom?

Yes No

Does your child need assistance in the restroom?

Yes No

If yes, please explain
If no, write "none"

Does your child feed himself/herself independently?

Yes No

Does or has your child physically attacked others?

Yes No

If yes, please explain
If no, write "none"

Does your child excessively manipulate their genital area in public?

Yes No

Can your child participate in outdoor activities?

Yes No

Does your child run away or wander off from groups or adults?

Yes No

Has your child ever had a seizure?

Yes No

If yes, date of last seizure

Please describe any challenging behaviors your child exhibits
Indicate "None" if not applicable

What are some triggers for this behavior?
Indicate "None" if not applicable

What typically upsets your child?

What typically calms down your child?

What are your child's favorite activities?

List additional information that might contribute to a positive program experience

What is your child's shirt size?

If my child exhibits aggressive/uncontrollable behavior (i.e. hitting, scratching, biting, etc.), I give permission for The Special Reach staff to passively restrain him/her and or use time out for 2-5 minute intervals (not to exceed 15 minutes total), until the behavior is under control. I understand that I will be notified if my child exhibits ongoing disruptive behavior and I (or the designated person) will pick up my child as soon as possible from the program.

Digital signature

Clear

Date

Medical Permission: In the event that I cannot be reached to authorize medical attention for my child, I authorize a representative of Special Reach to seek medical attention and grant medical staff permission to treat my child. I will not hold Special Reach staff liable for any accidental injury incurred by my child during the Special Reach program hours.

Child's Name

Digital signature

Clear

Date

Photo Release: I give permission for photographs or videos of my child to be used by Special Reach to portray and/or promote Special Reach activities. In no way will my child be exploited by the use of such photographs or videos.

Please select choice

Yes No

Digital signature

Clear

Date

Family Profile: Single parent families, please enter the same information into both Mother and Father profiles if applicable.

Mother's Name

Mother's Home Address

Mother's Cell Phone

Home Phone

Mother's Preferred Email

Mother's Place of Employment
Please type N/A if unemployed

Mother's Work Phone

Preferred Phone Number

Cell Home Work

Father's Name

Father's Home Address

Father's Cell Phone

Home Phone

Father's Preferred Email

Father's Place of Employment
Please type N/A if unemployed

Father's Work Phone

Preferred Phone Number

Cell Home Work

If you selected 'other', please specify:

Household Income:

How many people live in your household?

SIBLING INFORMATION: Please list names and ages of all siblings below.

List names and ages of all siblings

Do any siblings have special needs?

Yes No

Specify the name/s of the sibling/s that have special needs. Also, specify the diagnosis of each child.

List any additional sibling information.

Emergency Contact: Two alternate contacts - we need two people other than yourself to contact in case we can't reach you in the event of an emergency. We prefer that these people have contact numbers different than your own.

Name

Address

Cell Phone

Home Phone

Work Phone

Relationship

Name

Address

Cell Phone

Home Phone

Work Phone

Relationship

Authorized Pick up: I hereby authorize the Special Reach staff to allow my child to be released from the program to only the following people. Please be prepared to provide a government issued picture ID prior to pick up.

Name

Electronic signature

Clear

Date

To work with your child to the best of our ability it is imperative that we are aware of any physical limitations or medical conditions your child may have. Please note that all children are encouraged to participate only to the extent that they are able.

Please check one of the following areas.

My son/daughter may participate fully in physical activities My son/daughter is limited in physical activities. Please be specific:

Limited Physical activity Details:

Please email an official statement from your family physician that the child cannot participate in physical activities to special.reach@gmail.com.

My son/daughter is not allowed to participate in physical activities.

Additional Documents: Special Reach may request additional documents from you to help us meet your child's needs.

Late pick-up fee: $20 for the first 15 minutes after the program pick up time and $1.00 for every minute thereafter until your child is picked up. Special Reach Party Night is a Parents' Night Out program and not a licensed child/day-care facility. Our goal is that no child will be turned away for financial reasons.