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Parent Questionnaire
Pre-admission History
Participant: __________________________________________
- Has participant ever been involved in any other
recreation program?
Yes _______ No _______
If yes, where
______________________________________
- Does participant attend school? _________
Name: ________________________________________________________________
- Does participant work? __________
Where:________________________________________________________________
- What does participant do when not in school or work?
_____________________________________________________________________
- What aspect of our program would your
son/daughter most benefit from?
(Circle)
Social
Emotional
Physical Educational
- If your son/daughter could join any club, what would it be?
_____________________________________________________________________
- Does participant have any physical limitations
that will restrict him/her from engaging in certain
recreational
activities?
_____________________________________________________________________
- Is participant visually or hearing impaired?
_____________________________________________________________________
- Does participant use a wheelchair or walker?___________________________________
- Does participant have any behavioral
issues?___________________________________
Please specify:__________________________________________________________
_____________________________________________________________________
- What positive procedures do you recommend we use to prevent potential behaviors from occurring?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
- Is there an existing behavioral treatment plan
in place for this individual (yes) (no)
Please provide an up-to-date
copy so we can be consistent with individual's guidelines.
- Does participant need toileting assistance? Explain.
_____________________________________________________________________
_____________________________________________________________________
- Does participant wear Attends? (yes) (no)
- What is the best way to assist participant at
mealtime?
_____________________________________________________________________
_____________________________________________________________________
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