Participant’s Name M F DOB   Home Address City State Zip County Home Phone Send all e-mail correspondence to this e-mail: Ethnicity African American Asian Hispanic/Latino Caucasian Native American Multiethnic all that apply):       Mother’s Name Mother’s Employer Job Title _______________________________________________ Mother’s Work Phone Mother’s Cell Phone Mother’s Email Father’s Name Father’s Employer Job Title Father’s Work Phone Father’s Cell Phone Father’s Email Participant’s Physician Physician Phone Participant’s Therapist Therapist Phone how did you hear about us: Physician Case Manager School Friend/Family Website Other If you are a new Participant,       Current Residence (check one): Lives w/Family Foster Home Nursing Home Lives Independently Group Home Individualized Supported Living      Specialized Facility provide address and phone: If Group Home, PARTICIPANT PHYSICAL INFORMATION: Height Weight Verbal Non-Verbal   Ambulatory Non-Ambulatory   Wheelchair Walker Cane Diagnosis Seizure? Y N Allergies: Medications
Participant’s Name  M  F DOB Home Address City State Zip County Home Phone Send all e-mail correspondence to this e-mail: Ethnicity all that apply):  African American  Asian  Hispanic/Latino  Caucasian  Native American  Multiethnic Mother’s Name Mother’s Employer Job Title _______________________________________________ Mother’s Work Phone Mother’s Cell Phone Mother’s Email Father’s Name Father’s Employer Job Title Father’s Work Phone Father’s Cell Phone Father’s Email Participant’s Physician Physician Phone Participant’s Therapist Therapist Phone If you are a new Participant, how did you hear about us:  Physician  Case Manager  School  Friend/Family  Website  Other Current Residence (check one):  Lives w/Family  Foster Home  Nursing Home  Lives Independently Group Home  Individualized Supported Living Specialized Facility If Group Home, provide address and phone: PARTICIPANT PHYSICAL INFORMATION: Height Weight  Verbal  Non-Verbal  Ambulatory  Non-Ambulatory Wheelchair Walker Cane Diagnosis Seizure? Y N Allergies: Medications
2018%20Rider%20Packet.docx