form

Has your child been hospitalized recently? *

Yes

No

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 your son/daughter's favorite activities and hobbies.

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

Home Phone Number *

Address *

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?

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

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. *

Please upload a copy of the back of your child's insurance card *

Additional concerns, instructions, or questions:

Diagnosis *

Please upload a copy of the front of your child's insurance card *

Father's Cell *

Mother's Name *

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 *

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

Mother's Cell *

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") *

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