Monett Summer Program Monett Summer Program Registration Step 1 of 6 16% General Information Participant Name First Last Date of Birth MM slash DD slash YYYY Sex Phone Number Current Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School attending:(Required) Teacher(Required) Grade(Required) Classroom Assignment(Required) SRC Case Coordinator(Required) Parent or Guardian(Required) Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Address Primary Language Secondary Language Primary Diagnosis or Disability Secondary Diagnosis or Disability You must list 2 emergency contacts Emergency Contact Information #1 Name Work PhoneHome PhoneCell Phone Emergency Contact Information #2 Name Work PhoneHome PhoneCell Phone Emergency Contact Information #3 Name Work PhoneHome PhoneCell PhonePrimary Physician Phone Number Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Health History Medication taken? Yes No If you answered yes, the following MUST be completed. In case of a medical emergency, we need to know what medication(s) are taken even if medication is NOT taken during recreation program hours.Name of Medications:Dose: Time to be given: Possible side effects: Asthma Yes No What is done to control/prevent an attack? Does you/the individual require an inhaler? Yes No Allergies Yes No Please list out allergies Do you/the individual carry an EpiPen? Yes No When should it be used (Be Specific)? Diabetic Yes No What shouldn’t you/the individual eat or drink? Feeding information Independent Needs some assistance Needs total assistance Pureed food Tube fed Deaf/Hearing Impaired Yes No How do you/the individual communicate? Nonverbal Yes No Can you/the individual communicate through a different means? Physically disabled Yes No What is the disability? Wheelchair/Walker/Cane/Crutch Yes No What type? Electric wheelchair Manual wheelchair Walker Cane/Crutch Participant is: Independent Needs assistance Physical limitations Yes No What physical limitations? Safety Harness or Gait Belt Required Yes No What type? Bus Classroom In community Heart condition Yes No What heart condition? Seizures Yes No What happens before the seizures? Frequency of seizures? Date of last seizure? MM slash DD slash YYYY Exposure to Sun? Full Minimum No Exposure Sunscreen may be used Swim experience Yes No Previous swim experience level & location Toileting information Toilet trained Needs some assistance Needs total assistance Wears Diapers What assistance is needed? Are there any Health/Medical Concerns? Likes of the Individual Dislikes of the Individual Desired Outcomes and Expectations to be accomplished from this Program (Be Specific)Any other information that would be of assistance in serving the Individual?Parent or Guardian Signature(Required) Date(Required) MM slash DD slash YYYY The Arc of the Ozarks Field Trip Permission Form I (parent/guardian) hereby give (participant) permission to go on all Field Trip outings with the Education/Recreation Department including, but not limited to the Continuing Education and Saturday Recreation programs. Participants in activities offered by The Arc of the Ozarks are not covered by medical or accident insurance. Each participant must furnish his/her own personal coverage. As a participant (or as a parent of an MR/DD participant), I release The Arc of the Ozarks board members, volunteers and employees from any liability to the participants for any personal injury or property damage suffered by the participants as a result of participation in the program. I assume all responsibility and agree to indemnify the sponsors and hold the sponsors harmless from and against any and all liability or cost arising from or in connection with the participant’s participation in the program. In case of accident or sickness, I consent to emergency medical care provided by the ambulance or hospital personnel. Parent or Guardian Signature Date MM slash DD slash YYYY The Arc of the Ozarks Swimming Permission Form I (parent/guardian) hereby give (participant) permission to go swimming. Participants in activities offered by The Arc of the Ozarks are not covered by medical or accident insurance. Each participant must furnish his/her own personal coverage. As a participant (or as a parent of an MR/DD participant), I release The Arc of the Ozarks board members, volunteers and employees from any liability to the participants for any personal injury or property damage suffered by the participants as a result of participation in the program. I assume all responsibility and agree to indemnify the sponsors and hold the sponsors harmless from and against any and all liability or cost arising from or in connection with the participant’s participation in the program. In case of accident or sickness, I consent to emergency medical care provided by the ambulance or hospital personnel. Parent or Guardian Signature Date MM slash DD slash YYYY The Arc of the Ozarks School Visit Permission Form I (parent/guardian) hereby give The Arc of the Ozarks permission to visit my child in regards to his/her participation in the programs offered by the Education/Recreation Department. Child’s name School name Grade Teacher I may revoke this authorization at anytime, except to the extent that action had been taken in reliance thereon. This authorization (unless expressly revoked earlier) expires one year from the date below.Parent or Guardian Signature Date MM slash DD slash YYYY The Arc of the Ozarks Publicity Release I, (parent/guardian) hereby authorize The Arc of the Ozarks to include (participant’s) name and/or picture in the following: Public materials (Magazines, newspapers, etc.) Promotional Materials (Websites, brochures, displays, etc.) Organizational Materials (Employee mailings, training media, etc.) This authorization may be revoked by me at anytime, except to the extent that action had been taken in reliance thereon. This authorization (unless expressly revoked earlier) expires one year from the date below.Camper’s Name(Required) Signature of guardian(Required) Date(Required) MM slash DD slash YYYY Δ
