Registration

Participant's Name (as it appears on SS card):

First name

Last name

Gender

Female

Male

Participant's Email (or primary contact if none)

Phone (or primary contact if none)

Participant's Home Address

Is the participant their own legal guardian?

Yes

No

Parent/Guardian Name

Guardian Phone Number

Guardian Email

Is the participant their own re payee (if no, then who)?

Preferred Contact?

Email

Phone

Emergency Contact Name, Relationship and Phone Number

What is the participant's occupation, school, and/or day program being currently used?

Partiipant's Primary Health Insurance Provider

Secondary Health Insurace Provider (if applicable)

Current medications (if applicable)

Current Diagnoses

Do you have any allergies? If "yes" please explain.

Do you have any behavioral issues? If yes, what are they? Any physical aggression or self-injury? Please describe

Do you have a Behavioral Service Plan?

Are any communication devices utilized? If so, what device and what program/apps do you use and how often do you use it?

Are any mobility aid or adaptive equipment utilized? If so, what do you use and how often do you use it?

Is one-to-one service required?

Can participant work in groups?

Yes

No

Is the participant ok working with staff or being in a group with participants of the opposite sex? If no, please explain

Should the above registrant be stricken in any way and in the opinion of the support staff in charge, should require emergency treatment, should staff seek medical help, including surgery?

Care Management &
Staffing, LLC