Name: ______________________________________ Birthdate:_______________________
Home Phone: _________________________ E-mail Address: ______________________________
What is your preference for Monthly Calendar: Mail or E-mail?
Address: ___________________________ City:_______________________ Zip: _______________
Parent/Guardian: ___________________________________________________________________
Emergency Information (# for emergency contact of parent/guardian and/or other emergency contacts): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any emotional/behavioral concerns: It is required that you inform us of any potentially aggressive or violent behaviors and any know triggers of these behaviors. This information will not exclude the participant from the center, it will allow us to provide a safe environment. Please speak to the director with any concerns you may have. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Doctor & Phone: ____________________________________________________________________
Please list all current medications (When changing medications and/or dosage it is advised that participants do not attend the program until adjusted): ____________________________________________________________________________________________________________________________________________________________________
List allergies/medication concerns: __________________________________________________________________________________
Any other information: __________________________________________________________________________________
Permission to photograph/videotape for scrapbooks and future publicity of the Max Higbee CRC:
Signature: _________________________________
I hereby consent to treatment of my child for minor injuries by a qualified staff person. In the event of a serious injury, my child will be transported by ambulance or aid car to an emergency center for treatment. If I cannot be contacted, I further consent to the medical, surgical, and hospital care, treatment and procedures provided by a licensed physician or hospital when deemed immediately necessary or advisable by the physician to safeguard my child's health.
Signature: _________________________________
I hereby give permission for my child to participate in Max Higbee CRC Community Access Program activities.
Signature: _________________________________

The Max Higbee Center is committed to providing activities that are of interest and enjoyable to our clients. Please complete this Survey to help us facilitate a successful experience for your loved one(s).

How can we encourage positive behavior? ________________________________________________________________________________________________________________________________________________________________________________________________________________________

How can we discourage negative behavior? ________________________________________________________________________________________________________________________________________________________________________________________________________________________

What goals (if any) would you like to achieve with the Max Higbee Center? ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list any activities/events that you would like to see at the CAP? _______________________________________________________________________________________________________________________________________________________________________________________________________________________

Please give any suggestions as to how the CAP could be improved: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________