Participant's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Parent/Guardian Name

First Name

Last Name

Phone

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Phone *

(###)

###

####

Is your child on any medication? *

YES

NO

Check all that apply... *

Fully independent in ambulation

Needs assistance walking

Needs assistance with wheelchair

Requires a gait aid (ie. cane, walker, AFO)

Other

Primary mode(s) of communication *

Verbal

Sign Language

Gestures

Picture Symbols

Other

Does your child have a written learning and/or behaviour support plan for home, school or community? *

YES

NO

The above information is true to the best of my knowledge I and agree to notify the staff at Fiddlehead Care Farm if there are any changes. *

YES

NO