Annual Application

Annual Application
  1. Participant Information
  2. (required)
  3. (required)
  4. Participant Gender:
  5. (required)
  6. (required)
  7. (required)
  8. (required)
  9. (required)
  10. (required)
  11. Preferred Method of Contact:

  12. Participant living arrangements:

  13. Does the Participant attend school?
  14. Does the Participant attend a Day Program?
  15. Is the Participant Employed?
  16. DISABILITY TYPE
  17. Type of Disability:

  18. SPECIALIZED EQUIPMENT
  19. Specialized/Adaptive Equipment used:


  20. MEDICAL INFORMATION
  21. Medical Information:

  22. MEDICATION LIST
  23. Does the Participant take any medication?:
  24. If the Participant isn't on any medication, please skip to next section
  25. Will the Participant Require Medication during a RADD Activity?
  26. MEALTIMES
  27. Food Allergies
  28. Does the Participant have a G-tube or J-tube?:
  29. If the Participant is tube fed, are they allowed anything by mouth?:
  30. TRANSFERRING INFORMATION

  31. TOILETING

  32. Does the participant use
  33. Does the participant need assistance with Menstrual Care?:
  34. DRESSING
  35. The participant dresses:

  36. The Participant can:
  37. BEDTIME ROUTINE
  38. COMMUNICATION
  39. Participant is
  40. Participant uses Sign Language?:
  41. Participant uses a communication device?:
  42. Participant understands and follows directions?:
  43. Participant consistently expresses their own needs?:
  44. Participant Needs a Picture Schedule?:
  45. BEHAVIOR/COMPLIANCE
  46. Participant Bites, Kicks or Hits Others?:
  47. Participant displays self abusive behavior?:
  48. Participant is verbally aggressive (Yells, curses or name calls)?:
  49. Participant is destructive of property?:
  50. Participant is able to control temper?:
  51. Participant reacts appropriately when frustrated?:
  52. Participant respects others personal space?:
  53. Participant waits his/her turn?:
  54. Participant exhibits inappropriate behaviors due to obsessions?:
  55. Participant refuses to participate?:
  56. Participant reacts well to changed routine?:
  57. Participant avoids task?:
  58. SELF STIMULATING BEHAVIORS
  59. The Participant:

  60. Does the Participant Wander?:
  61. Does the Participant have a Behavior Intervention Plan?:
  62. ADDITIONAL INFORMATION
  63. SWIMMING
  64. The participant:

  65. SHOPPING/ORDERING
  66. The Participant:
  67. OTHER
  68. EMERGENCY CONTACT INFORMATION
  69. In the event of an emergency, we will attempt to contact the primary parents and caregivers listed first
  70. PRIMARY CONTACT 1:
  71. (required)
  72. (required)
  73. (required)
  74. PRIMARY CONTACT 2:
  75. EMERGENCY CONTACT 1:
  76. EMERGENCY CONTACT 2
  77. YOU ARE ALMOST DONE!
  78. DEMOGRAPHICS
  79. The following questions are for statistical purposes which assist us in getting funding to keep our activities going.
  80. Participants Ethnic Background:

  81. Annual Household Income (If participant is over 18, please indicate only the participant's income):


  82. Please list the individuals residing in the household where the participant lives:
  83. The participant's home is located:
  84. T-shirts are sometimes received at events. What size does the participant wear?:
  85. Youth Size:
  86. Adult Size:

  87. RADD LIABILITY WAIVER Part 1
  88. As a consideration for being permitted to participate in activities sponsored by RADD, also known as the Cerebral Palsy Agency of Racine County, Inc., and/or using equipment, facilities or property of said establishment, such client or user agrees to assume all liability for injury and/or damage resulting from such participation or use and further agrees to hold the Cerebral Palsy Agency of Racine County, Inc. free and harmless on account of any act of omission, commission, or negligence on the part of the Cerebral Palsy Agency of Racine County, Inc. or any of their officers, agents, employees or volunteers.
  89. RADD LIABILITY WAVIER Part 2
  90. RADD may photograph said client together with any subject matter owned by the undersigned, and so hereby authorize the Cerebral Palsy Agency of Racine County Inc. to cause the same to be exhibited as still photographs, transparencies, motion pictures and/or television. The undersigned does hereby release the Cerebral Palsy Agency of Racine Inc. its employees and agents from any and all claims for damages, libel, slander, invasion of the right of privacy, or any other claim based on the use of said material.
  91. RADD LIABILITY WAIVER Part 3
  92. In the event of an accident or sickness to said individual, the Director may obtain such medical, hospital or surgical assistance and service as he/she may deem necessary, and I/we here agree to pay such charges, indemnify RADD and hold same harmless for such charges. RADD may exchange information it possesses relative to said individual to any qualified agency or doctor, provided such information may be used for purposes of selection only.
  93. (required)
  94. You have now completed the Annual Application!
  95. Please press the Submit Button!
  96. Now, Take a Break! You Deserve it!