Has your child been hospitalized recently? *

Yes

If yes, please explain.

School/Day Program Currently Attending *

Please describe how your son/daughter interacts with peers in a group environment (shy, outgoing, aggressive, etc).

Father's Name *

Physician's Name *

Father's Email Address *

Mother's Email Address *

Participant's DOB *

How does your child react to changes in his/her daily routine? *

List all allergies/sensitivities. Please describe the allergic reaction and appropriate medical protocol. Has this reaction ever been anaphylactic? Is an Epi-Pen needed? (If no allergies, please write "NONE") *

Does your child utilize any medical equipment (ex. CPAP, BiPAP, nebulizer, oxygen, pulse oximeter, feeding tube, dexcom, catheter etc.) If yes, please explain in detail below. Please include schedule for use as well as relevant settings and protocols.

Please list your son/daughter's favorite activities and hobbies.

Does your child have any special dietary needs? If yes, please explain. *

Home Phone Number *

Address *

Are there any activities that your son/daughter should refrain from due to medical or other reasons? (Swimming, sports, outdoor activities, etc.) *

Please list your child's siblings' names and ages:

What will cause your son/daughter to become physically aggressive (hitting, kicking, biting, etc.) What interventions should be used?

Please describe your child's bathroom needs: *

Fully independent

Needs reminders

Requires partial assistance

Requires full assistance (not toilet trained)

Emergency Contact #1 (other than parent) *

Participant's Name *

Please list all medications, supplements, and vitamins. Please include the name of the medication, dosage, time it is taken, and method of delivery. Please be accurate and complete. If no medications are taken, please write NONE. *

Kool Kids Passaic

2024-2025 Information Packet

Additional concerns, instructions, or questions:

Diagnosis *

Father's Cell *

Mother's Name *

Comments

For participants ages 12 and older who have the personal safety skills to travel independently: Do you allow your child to walk home independently after programs? Please note that if you check yes, you are giving permission for your child to leave a program without waiting for a parent or other authorized adult to pick him/her up. *

Yes

N/A

Are there any particular activities that are beneficial to your child's health or physical needs? (swimming, sports, sensory play, etc.)

Mother's Cell *

What calming techniques does your son/daughter best respond to when he/she becomes upset or excited? *

Physician's Phone Number *

I hereby give consent for my son/daughter to attend Kool Kids Passaic Inc. and to participate in all activities, events, and trips. In addition, I give permission for Kool Kids Passaic Inc. to use photographs, videos, and voice of my son/daughter for any purpose, including print and electronic communication and publications. In the event of an emergency, I give Kool Kids Passaic Inc. permission to take measures to ensure the safety of my son/daughter including hospitalization. I understand that I will be notified as soon as possible. Type your name and today's date to serve as your electronic signature. *

Please list any medical concerns and explain appropriate medical protocol (seizure disorder, asthma, etc.) (If no medical concerns, please write NONE) *

Emergency Contact #2 (other than parent) *

Does your son/daughter fear swimming, darkness, loud noises, or any other activity?