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

PARTICIPANT TYPE *

Please give names of sibling or relatives attending OWCA Programs: *

Last Name *

First Name *

Middle Initial

Sex *

Birth Date *

Age *

Street Address *

Apt/Unit #

City *

State *

ZIP *

School

Grade

Diagnosis *

Househound / Adult Primary Contact

Relationship to Participant *

Primary language spoken in the home:(Check all that apply) *

First Name *

Last Name *

Check if address is same as above

Same as above

Street Address

City

State

Zip

Home Phone *

Cell Phone *

Email Address *

Medical Conditions

Is your child taking any medications? *

Yes

No

If yes, please describe:

0/100 characters

Are there any side effects to the medication? *

Yes

No

If yes, please describe:

0/100 characters

Does your child have allergies? *

Yes

No

If yes, please describe:

0/100 characters

Does your child have any dietary restrictions? *

Yes

No

If yes, please describe

0/100 characters

Does your child have any mobility requirements? *

Yes

No

If yes, please describe:

0/100 characters

Is there any other medical information that we should know about your child? Please explain:

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 *

	Independently	With Help	Needs Full Assistance
Toileting	Independently	With Help	Needs Full Assistance
Follows toileting routine (flush, dry hands etc)	Independently	With Help	Needs Full Assistance
Puts on and removes coat	Independently	With Help	Needs Full Assistance
Ties shoes	Independently	With Help	Needs Full Assistance
Wash hands	Independently	With Help	Needs Full Assistance
Eats with utensils	Independently	With Help	Needs Full Assistance
Cleans up personal items	Independently	With Help	Needs Full Assistance
Asks for assistance	Independently	With Help	Needs Full Assistance

Reinforcers

List your child's reinforcers (include social, tangible, and activities): *

0/350 characters

List your child's non-preferred activities/items:

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 *

No Behaviors

Has a behavior support plan (please attach a copy below)

Recognizes danger

Verbal aggression

Wandering/Running from group

Withdrawn/Shy

Responsible for personal items

Physical aggression, describe below

Self-Injurious behaviors, describe below Self-Injurious behaviors, describe below

Please describe in details any behaviors checked above

0/350 characters

Sensory

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

Please describe any calming techniques to use with your child should he or she become upset (i.e. deep pressure, swinging).

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. *

clear

Date *

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. *

clear

Date *

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. *

I grant permission to OWCA to photograph my child.

I do not grant permission for OWCA to photograph my child.

Please sign below. *

clear

Date *

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.

Last name *

First name *

Relationship *

Phone *

Phone number

Last name *

First name *

Relationship *

Phone *

Phone number

Last name

First name

Relationship

Phone number

Non-Verbal (Does not speak at all)	Verbal; can be clearly understood
Verbal; is difficult to understand	Limited understanding or receptive vocabulary
Understands and follows directions well	Uses gestures
Uses sign language	Needs time to process instructions
Needs reminders and cues	Uses communication device Uses communication device