Program Intake Form

Participant Name: *

First

Last

emergency same a

Date of Birth: *

Age: *

Multiple Choice *

Address: *

Home Ph# (no dashes): *

Cell Ph# (no dashes): *

Email *

Caregiver's Name: *

First

Last

Caregiver Relationship: *

Caregiver Ph# (no dashes): *

Caregiver Address: *

Caregiver Email: *

Doctor/Neurologist: *

Diagnosis (if available):

Emergency Contact same as above? If no, fill out emergency contact info below *

Emergency Contact:

First

Last

Emergency Contact Relationship:

Emergency Contact Ph#:

Emergency Contact Address:

Emergency Contact Email:

Are you able to pay $10.00 a day to attend each session? *