Client’s Siblings Name Age Gender Early Intervention Medical Insurance Private Pay Source of Funding Medicaid Med/Autism/DD/SS Waiver Other: Medical Insurance Provider Policy # Group # Plan Name Current Pediatrician or General Practitioner: Physician Phone Number: Physician Address: Diagnosing Dr.: Primary Diagnosis: Date of Diagnosis: Address: Phone #: Is your child currently or in the past been Date of Diagnosis: diagnosed with an infectious disease? Yes No □ □ If yes, please explain: Has your child been diagnosed with allergies? If Date of Diagnosis: yes, please indicate allergen. Yes No □ □ Other condition: Date of Diagnosis: Medication Information Is the client on medication? Yes No □ □ If yes, list medication information below: Medication Dosage Time Administered Purpose Will any of the above medication need to be administered during attendance at Autism Children’s Center? Yes No □ □
Client’s Siblings Name Age Gender Source of Funding Early Intervention Medical Insurance Private Pay Medicaid Med/Autism/DD/SS Waiver Other: Medical Insurance Provider Policy # Group # Plan Name Current Pediatrician or General Practitioner: Physician Phone Number: Physician Address: Diagnosing Dr.: Primary Diagnosis: Date of Diagnosis: Address: Phone #: Is your child currently or in the past been diagnosed with an infectious disease? □ Yes □ No If yes, please explain: Date of Diagnosis: Has your child been diagnosed with allergies? If yes, please indicate allergen. □ Yes □ No Date of Diagnosis: Other condition: Date of Diagnosis: Medication Information Is the client on medication? □ Yes □ No If yes, list medication information below: Medication Dosage Time Administered Purpose Will any of the above medication need to be administered during attendance at Children’s Autism Center? □ Yes □ No
Enrollment_Application_-_complete.docx