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2. 
3. Therapeutic Recreation New Participant Questionnaire
5. Participant's First Name*
6. Participant's Last Name*
8. Date of Birth*
9. Address*
11. Medical Insurance Provider*
12. Policy #*
14. Diagnosed disability and/or the nature of participant's challenges*
16. Gender*

    1. Male
    2. Female
    3. Prefer not to answer
17. Pronouns
21. Currently taking any medications?*

    1. Yes
    2. No
22. If yes, please list medications and dosage
24. Will the medication need to be administered/taken by participant, parent, caregiver, or personal care assistant during program hours?*

    1. Yes
    2. No
25. If yes, please explain
29. School the participant attends*
30. Current grade*
31. Teacher*
33. Does the participant have an IEP?*

    1. Yes
    2. No
34. Does the participant have a 504 plan?*

    1. Yes
    2. No
36. Do you give permission for the Therapeutic Recreation staff to contact school personnel and share information?*

    1. Yes
    2. No
38. If over school age, any supplementary programs the participant attends*
40. Is the participant employed?*

    1. Yes
    2. No
41. If yes, employer and job title
45. Does the participant have epilepsy and/or experience seizures?*

    1. Yes
    2. No
46. If yes, please list the following:
48. Type of seizure
49. Current status (active or controlled)
51. Frequency
52. Typical / Average Duration
54. Date of last seizure
55. Known triggers
57. Reaction before, during, after seizure
59. Has the participant had any recent serious illness, injury or surgery?*

    1. Yes
    2. No
60. If yes, please explain
62. Does the participant have ANY allergies/sensitivities to food, medication, insect bites, or stings, etc? Please explain the nature of the allergy and the characteristics of the reaction*
64. Does the participant carry an Epi Pen?*

    1. Yes
    2. No
65. Does the participant follow a special diet we should be aware of?*

    1. Yes
    2. No
67. If yes, explain the diet here
71. Does the participant have a history of heart/lung/cardiovascular problems (Including but not limited to chest pain, blood pressure, cholesterol, asthma, heart attack, heart disease, difficulty breathing, and heart defects)*

    1. Yes
    2. No
73. If yes, please explain and describe any activity limitations
75. Does the participant have hearing/auditory issues*

    1. Yes
    2. No
76. Use hearing aids?*

    1. Yes
    2. No
78. Does the participant use ASL/gestures and/or any electronic devices/PECS to communicate?*

    1. Yes
    2. No
80. Is the participant able to communicate their wants/needs?*

    1. Yes
    2. No
81. Does the participant speak with a delay/slow speech?*

    1. Yes
    2. No
83. Please check any of the following activities of daily living where the participant will need assistance*

    1. Eating
    2. Drinking
    3. Toileting
    4. Dressing (zippers, shoelaces, buttons)
    5. Does not need any assitance
85. Please explain ADL assistance here if needed
89. History of concussions/head injuries?*

    1. Yes
    2. No
90. Does the participant experience any visual problems/blindness?*

    1. Yes
    2. No
92. Wear glasses?*

    1. Yes
    2. No
93. Does the participant have any bone and/or joint problems?*

    1. Yes
    2. No
95. Any mobility and/or balance concerns?*

    1. Yes
    2. No
96. If yes, please explain any limitations or when/where extra help will most likely be needed
98. Does the participant use any assistive devices or adaptive equipment (walker, crutches, prosthetics, cane, orthotics, etc.) on a daily basis? *

    1. Yes
    2. No
99. If yes, please explain
101. Can the participant read?*

     1. Yes
     2. No
102. Can the participant write?*

     1. Yes
     2. No
104. Does the participant have any sensory limitations or concerns that may interfere with programming?*

     1. Yes
     2. No
105. If yes, please explain
107. Does the participant have any psychological, emotional, or behavioral concerns or issues that may arise during social situations, new experiences, physical exertion, or stressful circumstances? (Including but not limited to anxiety, aggression, defensiveness, panic attacks, confusion, etc.)*

     1. Yes
     2. No
108. If yes, please explain
110. Please briefly describe the participant's social behavior*
112. Please list any leisure activities, sports, classes/programs that the participant enjoys in their freetime*
114. Please describe the participant's current living situation*
116. Is there any additional information you can provide about the participant and would like us to be aware of?*
118. The information provided on the previous page is current and accurate. I understand that this is personal information and that it will be confidential, and only pertinent information will be shared with inclusion support staff members on an as-needed basis, and will be kept on file by the Burlington Recreation Department's Therapeutic Recreation Specialist.
120. Signature of Parent/Legal Guardian/Caregiver*
121. Date*
125. School Information Release Form
126. 
128. I will provide (or) hereby give permission for my child's teacher to release his/her Individual Education Plan to the Burlington Parks and Recreation Department, (as well as provide written or verbal communication) for use by the Therapeutic Recreation Specialist, Recreation Therapist and Inclusion Staff.*
     -- Select One --YesNo
130. Participant Name
131. Date
133. Signature of Parent/Guardian
135. Teacher's Name
136. Teacher's Phone Number
138. Teacher's Email
140. I will provide (or) hereby give permission for my child’s _______________________ to provide written or verbal communication to the Burlington Parks and Recreation Department for use by the Therapeutic Recreation Specialist, Recreation Therapist and Inclusion Staff. *
     -- Select One --YesNo

     Other Providers Release Form (Example: ABA Therapist, Counselor, etc.) 

142. Participant Name
143. Date
145. Signature of Parent/Guardian
147. Provider's Name
148. Provider's Phone Number
150. Provider's Email
154. Tips and Tools

     Please fill out this page to give us a better understanding of your child's behaviors, skills and needs.

155. 
157. Has your child attended Recreation Department programs before?*

     1. Yes
     2. No
158. Does your child run away/bolt unexpectedly?*

     1. Yes
     2. No
160. Does your child exhibit any physically aggressive behaviors? (Ex: hitting, biting, kicking, scratching)*

     1. Yes
     2. No
161. If yes, towards self or others
163. Please list any possible triggers for aggressive bahviors*
165. Does your child show an interest in interacting with their peers?*

     1. Yes
     2. No
166. Is your child easily agitated/annoyed by others?*

     1. Yes
     2. No
168. Is your child able to manage their belongings?*

     1. Yes
     2. No
169. Does your child have a short attention span?*

     1. Yes
     2. No
171. Does your child prefer independent activities or group activities?*

     1. Independent
     2. Group
     3. Both
172. Is your child able to follow the rules of a game?*

     1. Yes
     2. No
174. Does your child have difficulty sharing items or taking turns?*

     1. Yes
     2. No
175. Is your child able to follow directions?*

     1. Yes
     2. No
176. My child can follow*

     1. 1-step directions
     2. 2-step directions
     3. 3-step directions
178. Is your child sensory sensitive and/or sensory seeking?*

     1. Sensitive
     2. Seeking
     3. Both
179. Please explain
181. How does your child do with transitions?*

     1. Great
     2. OK
     3. Not Well
182. What do you do at home/school to prepare your child for a transition?*
184. Are there any tools you use at home or school that might also be helpful during rec programs?*

     1. Yes
     2. No
186. Tools used for transitions/breaks/activities*

     (Check all that apply)

     1. Timer
     2. Social Stories
     3. Visual Schedules
     4. Written Schedules
     5. Verbal Warnings/Reminders
     6. Other
187. Other:
189. What behaviors does your child exhibit when scared/nervous/uncomfortable?*
191. Will your child ask for a break if they are feeling nervous/overwhelmed/tired?*

     1. Yes
     2. No
192. If no, are there any signs we should look out for to prompt a break?

     1. Yes
     2. No
194. Please list signs to prompt for a break:
196. Are there any items you will send with your child from home that will help with transitions, to use during a break, or to help your child calm down if upset?*

     1. Yes
     2. No
197. If yes, please list items
199. Will your child tell the staff if they need to use the bathroom?*

     1. Yes
     2. No
201. Please list 3 recreation, social, and/or skill based goals that you have for your child while they are at recreation department programs.*
203. Any other odds and ends we should be aware of before your child attends any programs*
207. 
208. Burlington Parks and Recreation Department Therapeutic Recreation Programs

     Traveling Emergency Form

210. Participant Name*
211. DOB*
213. Address of Participant's Primary Residence*
215. Parent/Guardian (Primary Contact) Name*
217. Primary Contact Cell Phone Number*
219. Emergency Contact Information

     Must have 2 people to call OTHER than primary contact above

221. 1.) Emergency Contact Name*
222. Relationship to Participant*
224. Cell Phone Number*
226. 2.) Emergency Contact Name*
227. Relationship to Participant*
229. Cell Phone Number*
231. Participant Information:
233. Diagnosis/Nature of Disability*
235. Medications*
237. Does this participant experience seizures?*

     1. Yes
     2. No
238. If yes, please provide a brief explanation and known triggers
240. All known allergies*
242. Mobility concerns*
244. Does the participant bolt or run away?*

     1. Yes
     2. No
245. If yes, please provide a brief explanation and known triggers
247. In case of an emergency- Level of Functional Verbal Communication*

     Choose one.

     1. Complete/Independent
     2. Limited Verbal Skills
     3. Able to Answer Yes/No Questions
     4. Non-verbal
249. Please upload a CURRENT photo of participant here*
Leave This Blank:


251. 1. Receive an email copy of this form.
252. Email address

     This field is not part of the form submission.

253. Submit Submit and Print

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