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First Name
Last Name
Email address
Password *
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For the First and Last name above, please ensure that it is the name of person involved in Dubasov, NOT of the parent/guardian.

Date of Birth
Gender
Address
City
Postal\Zip Code
Media/Photo Release


|============================= CLIENT ONLY SECTION =============================|

Parent/Guardian Name
Parent/Guardian Home No.
Parent/Guardian Work No.
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
|============================= TEACHER ONLY SECTION =============================|

Home Phone
Mobile Phone
Email Address
Occupation
Name of School or Daycare Currently Employed
Medical Information (Allergies, Medications, Medical Conditions, etc)
Reason for Attending Workshop
How did you hear about our workshop? (Please be specific)
Do you want to be added to our mailing list for future workshop/training opportunities?


|============================= VOLUNTEER ONLY SECTION =============================|

Home Phone
Mobile Phone
Email Address
Occupation
Education
Medical Information (Allergies, Medications, Medical Conditions, etc)
Doctor Name
Emergency Contact Name
Emergency Contact Home Phone
Emergency Contact Mobile Phone
Relationship with Emergency Contact
Reason for Volunteering