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Last Name
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Date of Birth
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Program/School
Media/Photo Release


Address
City
Postal\Zip Code
Parent/Guardian Home No.
Parent/Guardian Work No.
Parent/Guardian Name
Parent/Guardian Cell No.
Emergency Contact Full Name
Emergency Contact Relationship
Emergency Contact Phone Number
Community Support Worker/Caregiver Name (The individual whom, when applicable, will accompany participant to classes)
Community Support Worker/Caregiver Phone Number
Community Support Worker/Caregiver Email
How did you hear about Dubasov Dance and Wellness?
What goals would you like the participant to achieve through attending this program?
Participant's Formal Diagnosis
Doctor's Name
Allergies
Medications
Seizures (Severity/Frequency)
Hearing or Vision Impairments
Feeding Needs e.g. Feeding Tube
Toileting (Toilet Trained/Assist Level in Washroom)
Mobility (Ambulatory, Mobility Aids/Adaptive Equipment Used)
Speech (Verbal or Non-Verbal, Sign Language)
Ability to Understand and Follow Instruction
Behavioural Concerns e.g. May bolt from room, aggressive, shy, anxious, separation anxiety
Sensory Needs e.g. High or low arousal levels, hyper/hypo sensitivities to touch/sound, oral defensiveness
Behavioural/Sensory Strategies in Place e.g. Chew toy, visual supports, choices, reinforcers
Other Relevant Information