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Parent's Night Out Registration
May 21, 2022
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* Indicates required question
Phone Number
*
Your answer
Email Address
*
Your answer
Child's First and Last Name
*
Your answer
Nickname/Name the Child goes by if different than above
Your answer
Diagnosis
*
Your answer
Birthday
*
MM
/
DD
/
YYYY
Insurance Carrier
*
Your answer
Insurance Policy Number
*
Your answer
Policy Holder's Name
*
Your answer
Physical Needs: Vision
*
Typical
Impaired
Blind
Other
Physical needs: Hearing
*
Typical
Impaired
Deaf
Hearing Aid
Other:
Physical Needs: Motor Function
*
Head Control
Rolls Over
Sits
Crawls
Cruises
Walks
Walker
Crutches
Braces
Wheelchair
Other:
Physical Needs: Toileting Skills
*
Toilets Independently
Needs Assistance
Wears a Diaper
Being Potty Trained
Other:
Physical Needs: Eating Habits
*
No Restrictions
Nothing by Mouth
Soft Foods Only
Bottle
Other:
Feeding Instructions or tips
Your answer
List all Medication your child is currently taking
*
Your answer
List any allergies (food, drug, etc.)
*
Your answer
List any relevant medical information.
*
Your answer
Does your child have a history of seizures? If so, please explain.
*
Your answer
Communication
*
Verbal
Limited Verbal
Nonverbal (no communication device)
Nonverbal (uses a communication device)
Other:
Required
Can understand what others say:
*
All of the time
Most of the time
Some of the time
Please provide any additional information for any boxes checked "other".
Your answer
Please provide us with a brief rundown of your child's behavior as well as their likes and dislikes.
*
Your answer
Please provide any additional information that may be helpful for our staff/team members in working with your child.
Your answer
I would also like to enroll a sibling.
*
Yes
No
Sibling's name
Your answer
Sibling's age and birthday
Your answer
Sibling's Gender
Female
Male
Clear selection
Does the sibling have any allergies? Please list as well as any other medical notes about the sibling.
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
*
Your answer
List any additional individuals who are authorized to pick up the participant.
Your answer
By providing my electronic signature, I agree that I have fully disclosed to The Assembly Cabot all pertinent facts about my child's special needs and accept full responsibility for failure to do so.
*
Your answer
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