subject_line
MOVING FORWARD DAY PROGRAM
Background Information &
Enrollment Form
CLIENT INFORMATION
First Name
*
Last Name
*
Date of Birth
*
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Street Address
*
City
*
Province
*
Postal Code
*
Home Phone Number
*
OHIP No:
*
Name of Primary Physician
*
Medical Facility Name:
*
Street Address
*
City
*
Phone Number
*
PARENT INFORMATION & EMERGENCY CONTACT
Parent First Name
*
Parent Last Name
*
Relationship
*
Street Address
*
City
*
Home Phone Number
*
Mobile Number
*
Email Address
*
Same address as above
*
Yes
No
City
*
Province
*
Postal Code
*
Home Phone Number
*
Mobile Number
*
In case of emergency, contact parent indicated above
*
Yes
No
If "no", please provide alternate emergeney contact:
First Name
*
Last Name
*
Relationship
*
Home Phone Number
*
Mobile Number
*
MEDICAL BACKGROUND
Diagnosis Information - please check all applicable boxes:
*
Autism
Vision Impaired
FASD
Hearing Impaired
Brain or Neurological
Cerebral Palsy
Epilepsy
Down Syndrome
Physical Disability
Mood Disorder
Depression
Developmental Delay
Other
Other
Provide additional details on diagnosis, as required:
Allergies:
*
Yes
No
If "yes", please provide additional details:
*
Currently taking medication:
*
Yes
No
Med #1
*
Frequency
*
Dosage
*
Med #2
Frequency
Dosage
Will medication need to be administered by the Moving Forward Day Program
*
Yes
No
If "yes", please provide details below:
*
NEEDS ASSESSMENT
Mobility
*
Walks independently
Walks with aids, i.e., cane, crutches
Requires one-to-one assistance
Non-ambulattory
Usually in a wheelchair
Other
Other
Literacy
*
Able to read
Able to write
Can recognize numbers
Other
Other
Independence
*
Requires minimal supervision
Requires constant supervision
Other
Other
Self Care
*
Able to wash hands
Able to toilet independently
Able to feed independently
Able to dress independently
Able to put on boots, shoes & outer jacket
Other
Other
Please provide any additional information that you believe is relevant:
BEHAVIOURAL
Please provide details of any behavioural issues:
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