OWCA 2017-2018 Participant Profile

The One World Center for Autism, Inc.
7401 Forbes Blvd Suite-A
Lanham Md 20706
If you have any questions, please call 301-618-8395!

Participant Information

Househound / Adult Primary Contact

Primary language spoken in the home:(Check all that apply) *
 
Check if address is same as above

Medical Conditions

Is your child taking any medications? *
0/100 characters
Are there any side effects to the medication? *
0/100 characters
Does your child have allergies? *
0/100 characters
Does your child have any dietary restrictions? *
0/100 characters
Does your child have any mobility requirements? *
0/100 characters
0/250 characters
PLEASE NOTE: WE CANNOT GIVE MEDICATIONS TO YOUR CHILD.  IN THE EVENT OF AN EMERGENCY, YOUR CHILD WILL BE TRANSPORTED TO THE NEAREST HOSPITAL

Self Help Skills

Indicate the skill level for each *
 IndependentlyWith HelpNeeds Full Assistance
Toileting
Follows toileting routine (flush, dry hands etc)
Puts on and removes coat
Ties shoes
Wash hands
Eats with utensils
Cleans up personal items
Asks for assistance

Reinforcers

0/350 characters
0/350 characters

Communication

How does your child communicate with you? Check all that apply. *
 
Please bring any equipment needed for successful communication.

Behavior/Safety

Please check all that apply *
 
0/350 characters

Sensory

Does your child have sensitivity to any of the following? Please check all that apply and provide a description. *
 

Waiver Liability

I agree to waive and relinquish all claims and to fully release discharge, indemnify, hold harmless and defend The One World Center for Autism (OWCA) and its employees, volunteers, agents, and servants from any and all claims resulting from injuries, including loss of life, personal injuries, property damages, and expenses, sustained by me/my child arising out of, connected with, or in any way associated with the activities of the program.  The participant assumes all risks associated with participation in the program; OWCA assumes no liability for injury or damages arising from participation in the program.  The child's parent or guardian is encouraged to consult his or her physician concerning the participant's fitness to participate in OWCA programs.  
By signing below, you are indicating that you understand and adhere to the Waiver of Liability. * 
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Medical Release

In case of emergency, accident or illness, I give my permission for the above participant to be treated by a professional medical person and admitted to a hosipital, if necessary.  I agree to be the party responsible for all medical and hospital expenses incurred on behalf of the above participant.  If there are any special auxiliary aids or services necessary in order to reasonably accomodate the particpant with a disability to enable them to have an equal opportunity to participate in and enjoy the benefits of the program or activity, please specify them on a separate, confidential sheet.
By signing below, you are indicating that you understand and adhere to the Medical Release Policy. * 
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Photo Release

OWCA is an organization dedicated to providing the best practices to individuals and families affected with autism and other developmental disabilites.  It is our belief that training and educating all parties who surround a child are essential to the development of the whole child.  Therefore, OWCA may take pictures of your child and/or videotape therapy sessions.  The photographs and video will be used for training purposes for educators, parents, and therapists for example.  OWCA will also conduct activities that may be publicized through local or national news/social media.  Photography or video used for publication may include but are not limited to brochures, flyers, OWCA's website and newsletters. 
Click here to indicate permission to have your child be video taped or photographed. *
Please sign below. * 
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Emergency/Transportation Contacts

I hereby authorize the following individual(s) listed below to pick up my child from classes held at The One World Center for Autism (OWCA).  I agree to notify all staff a week in advance when I will not be available to pick up my child.  I understand that OWCA will not release my child to any individuals not listed below.  All non-parents/guardians listed below must show an ID in order to pick up a child.