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ADAPTIVE GYM PARTICIPANT INTAKE FORM

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*
Date of Birth
Information
6. Diagnosis:
7. Level of Disability for transfers (check select 1)*
8. Daily attitude/general disposition (choose number most appropriate on scale)*
1 Very Happy
2
3
4
5 Very unhappy & agitated
9. Fear of Movement*
1 - No Fear
2
3
4
5 - Very Fearful
10. Can participant verbally communicate?*
No
Yes
11. If NO to Question 10, describe mode of communication
12. Can participant follow basic safety instructions?*
No
Yes
13. Height
14. Weight
15. Other movement/exercise activities currently participating in: (please list)
16. Level of interest in participating in movement (select number most appropriate on scale)*
1 - Very Interested
2
3
4
5 - Very Hesitant to participate
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.


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