Membership Application

Enrollment Information

Membership Level:

FCR Membership

Please indicate ALL areas of enrollment:

Catalog (access to all activities)

Special Events

Independent Activities

Dances

Member Information

First Name: Last Name: Home Address: Apt. # City: State/Province: Zip Code: - Phone: Phone: Email: Mailing Contact

Parent(s)

Guardian

Residential Contact

Other Relative

Other

Name Address City: State: Zip: -

Member Demographics

Birth Date: / / Gender

Male

Female

Gender Fluid

Gender Neutral

Other

Prefer not to say

Ethnicity/Race

African American/Black

Asian

Bi-racial

Caucasian

Hispanic

Latino

Multi-racial

Native American

Prefer not to answer

Religious Preference

Log-in Information

Please create a user name and password so that you can access your account.

Activity Reminder Contact Information

Please list the best number and email to send reminders to ensure members know their upcoming activities. It must be a line that is monitored by a person.

Please list the best number to call for reminders about scheduled activities. Please list the best email to send reminders about scheduled activities.

Current Living Arrangements

What is the participant's living situation?

Group Home

Supported Living

Home with Family

Independently

Name of Residential Agency Name of residential manager Residential manager's phone # Residential manager's email Support Staff Name (that works with the participant) Support Staff Phone # (that works with the participant) Name of Service Coordinator: Service Coordinator's Phone #: Service Coordinator's Email:

Guardian Information

Own Guardian

Yes

No (if no please complete guardian information)

Guardian Name Guardian Address Guardian's Relationship to participant Guardian E-mail Guardian Home Phone #: Guardian's Work Phone #: Guardian's Cell #:

Medical Information

Please list the medical diagnosis of the participant: Franklin County Health Form Please list Medications, the reason for the medication and any drug reactions: Does the participant have allergies?

Yes

Please list any known allergies. (if none write NA) Does the participant have a current ISP/BSP?

Yes

Food Restrictions

Yes

List restrictive foods (if none write NA) Doctor's name and number Please comment on any physical limitations this person might have in doing recreation activities. Preferred hospital for treatment in case of an emergency.

Social/Community Interaction

Please make sure that the person filling out this series of questions knows the applicant well. The accuracy of this information is important to meet the applicant’s needs while attending Franklin County Recreation.

Can the applicant express wants and needs verbally?

Yes

Sometimes

Does the applicant use sign language?

Yes

Sometimes

Does the applicant understand simple sentences?

Yes

Sometimes

Does the applicant engage in any violent, aggressive or self-abusive behavior?

Yes

Sometimes

Does the applicant have a current behavior support plan?

Yes

Sometimes

Does the applicant stay with group activities?

Yes

Sometimes

Does the applicant have alone time in the community?

Yes

How much alone time does the applicant have? Can the applicant ride public transportation independently?

Yes

Sometimes

Can the applicant leave to use the restroom & return independently to the group?

Yes

Sometimes

Does the applicant demonstrate safe pedestrian skills in the community?

Yes

Sometimes

Does the applicant display appropriate behavior in public?

Yes

Sometimes

Does the applicant need assistance in eating?

Yes

Sometimes

Does the applicant display appropriate behavior with respect to sexual behavior?

Yes

Sometimes

Does the applicant take medication independently?

Yes

Sometimes

Does the applicant take care of personal hygiene needs?

Yes

Sometimes

Does the applicant change their clothes independently?

Yes

Sometimes

Does the applicant take care of personal toileting needs?

Yes

Sometimes

Does the applicant interact well with peers?

Yes

Sometimes

Does the applicant independently follow through with friendships?

Yes

Sometimes

Does the applicant set limits with strangers?

Yes

Sometimes

Does the applicant ask questions when needed?

Yes

Sometimes

Does the applicant independently plan their leisure time?

Yes

Sometimes

Does the applicant independently carry on a conversation with others?

Yes

Sometimes

Does the applicant independently engage in hobbies?

Yes

Sometimes

Does the applicant independently know what to do in case of an emergency?

Yes

Sometimes

Does the applicant independently read survival words?

Yes

Sometimes

Does the applicant demonstrate a variety of leisure interests?

Yes

Sometimes

Does the applicant have a fear of cats, dogs, or other animals?

Yes

Sometimes

Can the applicant use a swimming pool with minimal supervision?

Yes

Sometimes

Does the applicant use: (select all that apply)

N/A

wheelchair

walker

crutches

cane

AFO

Please fax the ISP/BSP to 614-607-7825 or email it to cstokes@addohio.org Attn: Carla Stokes.

Additional Contact Information

Contact Kind

Parent/Guardian

Residential Manager

Residential contact

Emergency contact

Support Staff

Service Coordinator

Employer

Contact Relationship Contact Title

Mr.

Mrs.

Dr.

Miss

Attorney

Contact Last Name Contact First Name Contact Address1 Contact Address2 Contact City Contact State Contact ZIP Contact Person Email Contact Home Phone Contact Work Phone Contact Cell Phone Contact Fax Contact Other Phone Contact Mail All Info