Loading...

Entrance Criteria & Emergency Information

Please complete all sections of this form. The form must be on file in order to participate in any ABC Hopes, Inc. event when parent/ guardian is not present. Periodic updates of this form may be requested.

 

Liability Release and Photo Consent Form

In consideration of participation in programs with ABC Hopes, Inc., for myself and (if I am not the program participant) and on behalf of the program participant identified below, I hereby expressly release and discharge ABC Hopes, Inc. and its predecessors and successors in interest, subsidiaries, affiliates, and its past and present directors, officers, agents, servants, employees, representatives, administrators, assigns, contractors, and volunteers (collectively, the “Releases”) from any and all claims for damages, injury and/or equitable relief, including without limitation workers’ compensation claims, that may arise out of or be related to participation in the program, to the maximum extent permitted by the law now or in the future, and I expressly waive such claims.

I further agree, on behalf of the program participant and/or on my own behalf, that I/she/he will indemnify and hold harmless releases from any loss, damage, claim, or liability, including attorneys’ fees, incurred by reason of participation in the program.

In addition, I grant permission, (both during and any time after), to ABC Hopes, Inc. to use my/her/his likeness, name, voice or words in either television, radio, film, newspaper, magazines, electronic media, and in any other form for advertising and/or communicating the purpose and/or activities of ABC Hopes, Inc. and/or applying for funds to support these purposes and activities.

I acknowledge that I have read the above statements and understand their contents, and that I agree to such terms and conditions. (please initial).


 

Date: December 21, 2024

First ABC Hopes Participant's Name

First Name*

Last Name*
First ABC Hopes Participant's Date of Birth*
First ABC Hopes Participant's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
First ABC Hopes Participant's Signature*
Second ABC Hopes Participant's Name

First Name*

Last Name*
Second ABC Hopes Participant's Date of Birth*
Second ABC Hopes Participant's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
Second ABC Hopes Participant's Signature*
Third ABC Hopes Participant's Name

First Name*

Last Name*
Third ABC Hopes Participant's Date of Birth*
Third ABC Hopes Participant's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
Third ABC Hopes Participant's Signature*
Fourth ABC Hopes Participant's Name

First Name*

Last Name*
Fourth ABC Hopes Participant's Date of Birth*
Fourth ABC Hopes Participant's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
Fourth ABC Hopes Participant's Signature*
Fifth ABC Hopes Participant's Name

First Name*

Last Name*
Fifth ABC Hopes Participant's Date of Birth*
Fifth ABC Hopes Participant's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
Fifth ABC Hopes Participant's Signature*
Sixth ABC Hopes Participant's Name

First Name*

Last Name*
Sixth ABC Hopes Participant's Date of Birth*
Sixth ABC Hopes Participant's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
Sixth ABC Hopes Participant's Signature*
Seventh ABC Hopes Participant's Name

First Name*

Last Name*
Seventh ABC Hopes Participant's Date of Birth*
Seventh ABC Hopes Participant's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
Seventh ABC Hopes Participant's Signature*
Eighth ABC Hopes Participant's Name

First Name*

Last Name*
Eighth ABC Hopes Participant's Date of Birth*
Eighth ABC Hopes Participant's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
Eighth ABC Hopes Participant's Signature*
Ninth ABC Hopes Participant's Name

First Name*

Last Name*
Ninth ABC Hopes Participant's Date of Birth*
Ninth ABC Hopes Participant's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
Ninth ABC Hopes Participant's Signature*
Tenth ABC Hopes Participant's Name

First Name*

Last Name*
Tenth ABC Hopes Participant's Date of Birth*
Tenth ABC Hopes Participant's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
Tenth ABC Hopes Participant's Signature*
Physical Fitness Readiness Questionnaire/Waiver
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

If yes, please explain:
2. Do you feel pain in your chest when you do physical activity?*

If Yes, please explain:
3. In the past month, have you had chest pain when you were not doing physical activity?*

If yes, please explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*

If yes, please explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?*

If yes, please explain:
6. Do you know of any other reason why you should not do physical activity?*

If yes, please explain
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact Number

Emergency Contact Number *

Emergency Contact Full Name *
My Hoper is most interested in:
ABC Hopes Options*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Home Street Address *

City *

State *

Zip/Postal *

Home Phone:

Participant Cell Phone:

Descriptive Information:


Participants Diagnosis/Description:

Height:

Weight:

Eye Color:

Hair Color:

Other Identifying Characteristics:

What is your ethnicity *
Please select your ethnicity*
Please select your race*

Legal and Living Status:

Legal Status:*

If conservator is other than parent, please provide the following:


Conservator Name:

Address:

Phone Number:

Cell:
Living Status:*

Physician Information:


Physician Name:

Physician Address:

Physician Phone:

Part B: Support Assessment

We would appreciate your honest evaluation of the participant's need for support during our activities and programs, to ensure success and their safety and the safety of those around them. ABC Hopes, Inc. reserves the right to determine participant suitability for programs on a case-by-case basis.

Please Check One:
1. Participant is independent and travels in his/her community unassisted. She/he will navigate an event site once familiar with the layout, follow directions readily and will probably be of assistance to others attending an event. Participant will need to be picked up by an authorized individual at the end of the event.
2. Participant is comfortable in group situations and typically adjusts to new situations well. She/he may need support in navigating to different locations at an event site. She/he responds well to verbal directions and is usually cooperative. Participant does not need one-on-one assistance, but requires supervision. Participant will need to be picked up by an authorized individual at the end of the event.
3. Participant is less confident in large group settings. She/he may be anxious about attending something new and may need the support of a consistent familiar face in order to adjust. Participant will need assistance navigating to different locations at the event site. One-to-one assistance may be necessary for participant to participate in activities successfully and to stay on task. Participant may or may not have challenging behaviors. Participant will need to be picked up by an authorized individual at the end of the event.
4. Participant requires a one-on-one assistance by a familiar support person to assure safety. Participant might unexpectedly attempt to leave site, requiring one-on-one assistance by a support person to assure safety. She/he may have other challenging behaviors and/or health issues. She/he will need to wait to be picked up by a parent/guardian at the end of the event. Participant will need to be picked up by an authorized individual at the end of the event.

NOTE: Support needs will be discussed with you to determine participant suitability for program type.

Check here if you can provide a one-on-one assistant for the participant.
I can

Suggestions for Support: Please complete all that apply.

1. Restroom: All ABC Hopes participants will be escorted to and from the restroom. Please select one:*

Please describe the level of support required:

2. What specific supports would help participant during events and activities?

3. If participant expresses frustration or anxiety by demonstrating challenging behaviors, what would those behaviors look like and what specific strategies would likely help alleviate frustrations/anxieties to prevent challenging behaviors?

4. What specific responses help when challenging behavior occurs?

Part C: Safety and Health Information


1.  Communication:


Please select one:*
Uses sign language:*
No
Yes
If YES to sign language:
ASL
SEE
Gestures

Uses an augmented communication device. Please describe:
2. Health and Dietary Information: Please check all that apply:
Gluten-free diet
Diabetes
Casein/lactose intolerance
Severe Allergies
Physically limiting heart condition
Asthma
Seizures
Hearing impairment
Visual impairment
Limiting physical disabilities (Wheel chair/walker)
Participant has no health problems that affect normal daily activity
Participant has no special dietary needs

If YES to Severe Allergies, please list:

if YES to Visual impairment - Please describe:

If YES to Limiting physical disabilities (Wheel chair/walker) - Please describe:
Is participant capable of monitoring her or his own diet for diabetes, milk allergies, gluten sensitivities, and/or appropriate portion size?*
No
Yes

Medications:


Please list all medications, including name(s), amount taken, and time(s) taken:

Click to customize text box label
Is participant capable of monitoring and administering her/his own medication?*
No
Yes

Please note: Staff and/or Volunteers are unable to administer medications.


Please provide any additional information regarding seizures, allergies, food allergies, special diet, medications, or other health related information pertinent to participating in ABC Hopes, Inc. activities.

If participant has a history of seizures or allergic reactions of any kind, the ABC Hopes Team will convene to develop a health action plan. 

I have read and understand the above statement

Please list anything else that you feel would be helpful for staff or volunteers to know regarding the participant:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!