Club Metro Participant Information Form

Participant Information Form

Thank you for being a part of our Club Metro program! Please fill out the form below with as much information as you can share. This will help us provide the safest and most exciting experiences for our Club Metro friends.

Don't forget to visit our Club Metro website page for upcoming activities! www.ExperienceSouthlakeTexas.com/ClubMetro

Date

mm/dd/yyyy

Participant Last Name

Participant First Name

Age

Date of Birth

mm/dd/yyyy

Address

City

Zip

Current Email

Disability

Accommodation needed for the program.

Parent Information

Parent/Guardian Name

Parent/Guardian Phone Number

Phone

Emergency Information

Best person and number to call during the program times.

Emergency Contact Name

Emergency Contact Phone Number

Phone

Medical Information

Does the participant walk independantly?

Yes

Please identify if any mobility devices are used or if assistance is needed.

Wheelchair, walker, etc.

Does the participant have allergies or dietary restrictions?

Yes

Seizure Information

If active seizures, please include details of seizure plan.

Does the participant have seizures?

Yes

Self Help Skills

Does the participant feed himself/herself and use a cup?

Yes

Does the participant use the toilet independently?

Yes

Does the participant wash his/her hands independently?

Yes

Please list any skills the participant needs assistance performing.

Communication

Communication Type

Verbally

Communication Board/Device

Sign Language

Other (Please specify below)

Does the participant recognize his/her name?

Yes

Does the participant understand simple direction?

Yes

Social

Does the participant show interest in others?

Yes

Is the participant tolerant of others?

Yes

Does the participant wander off or run away?

Yes

Does the participant swim independently?

Yes

Please describe any other social behaviors we need to know about.

Behavior/Personality

Does the participant have any sensitivity to touch, noise, textures, etc.?

Yes

Does the participant show aggression toward others?

Yes

Please list any emotional triggers and how the participant responds.

Does the participant have tantrums and what calms him/her when tantrums occur?

Please list any specific techniques/methods that the participant responds to when upset.

What prevention strategies or modifications are effective with this participant?

What are the participant's areas of strength and what activities do they enjoy?

Please list as many interests as possible. These are key to helping us plan the program!

Is there any other important information that would enhance the quality and enjoyment of the participant in our programs?

Describe any reason which may prevent the participant from participating in class activities.

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