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2009 Ski/Board-A-Thon
FMSO
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Emergency Form
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TRAIL Participant Intake
General Information
Parent(s) Name(s):
*
Child(ren) Name(s):
*
DOB:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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31
Year
2009
2008
2007
2006
2005
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2003
2002
2001
2000
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1998
1997
1996
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1989
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1935
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1933
1932
1931
1930
1929
1928
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1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
E-mail:
*
Phone:
*
Address:
*
City:
*
State:
*
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code:
*
Country:
Option 1
Option 2
Option 3
Developmental History:
Compared to other children, does/did your child have difficulty with:
Talking
Understanding
Gross Motor Skills
Fine Motor Skills
Early School Skills
Sitting Still
Playing/Socializing w/Others
Toilet Training
Explain:
Medical History:
If yes please explain at bottom:
Seizures
Serious Illness
Operations
Allergies
Head Injury
Abdominal Pains/Vomiting
Headaches
Ear Infections
Visual Problems
Currently on Medication(please list below)
Hyper/Hypo active
Demands Attention
Does Not Eat Well
Shy/Timid
Speech Difficulty
Mood Changes
Tantrums
Aggression
Depressed
Non-Verbal
Repeats Certains Acts Over and Over
Wanders Away
Cries Often
Explain:
Educational History:
Name of School:
School Address:
Contact Person at School:
Additional Educational Information:
Repeated a Grade
Attended Early Education
Passed Kindergarten Screening
Any Other Information You Would Like to Tell Us:
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