ACCESS of Wilmington, Inc.

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ACCESS Fit - Community
Participant Information
First Name *
Last Name *
Birth Date *	// (mm/dd/yyyy)
Email *
Parent/Guardian Name(s):
Primary Diagnosis *
Secondary Diagnosis
Please share any mobility impairments: *
How does the participant communicate?	Verbal Clearly Understood Verbal Not Clearly Understood Nonverbal Uses Sign/Gestures Uses Communication Device Other
Other:
Are there any sensory needs for us to be aware of?
Are there any unsafe behaviors that may be exhibited?
Are there any triggers, warning signs, or behavior support strategies for these behaviors?
Are there any adaptations we can make to ensure your success in the program?
What area do you want to focus on most?
What are your goals for the program?
Please list any fitness activities, sports, and/or games you enjoy:
Emergency Contact Name: *
Emergency Contact Number: *

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