INTAKE FORM

Mother/Father/Caregiver Name and Address

Emergency Contact Phone Number (if parents/caregivers can't be reached)

Participant's Doctor (Address and Phone Number)

Participant's Dentist (Address and Phone Number)

Participant's Siblings (please list all with age)

If yes, please explain (please put N/A if no)

Food to avoid eating and drinking?

If yes, please explain (please put N/A if no)

Signs, gestures, and words used to express toileting needs?

If yes, please explain (please put N/A if no)

What are the top 3 activities the participant enjoys?

What are the participant's strengths?

What are the participant's weaknesses?

Does the participant have any behavioral concerns (biting, hitting etc.)?

Does the participant have any specific calming aids or techniques? Please explain.

Does the participant have any siblings who would like to volunteer at TECpark? Please list names and ages. *Note TECpark Buddies are ages 14+ and will not be paired with a sibling.

Is there anything else you would like to share with our team?

Please type your full name below as your signature for the form above.