CUSR Annual Information Form (AIF)

The AIF contains extremely important participant information which is necessary for CUSR staff to plan and execute safe and enjoyable programs. This form will be updated at beginning of each calendar year. Once submitted please allow one business day for processing. If you have not heard anything within 24 hours, please reach out to us. AIFs are valid through April 30 each year. On May 1 a new one will need to be completed regardless of the last time one was submitted.

CUSR Confidentiality Statement

All information submitted is confidential and will not be shared with others outside of CUSR.

Date(Required)

Month

Day

Year

Particpant Name(Required)

First Last

Legal Guardian(Required)

First Last

Sex(Required)

Female

Male

Date of Birth(Required)

Month

Day

Year

Height(Required)

Weight(Required)

Participant Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Phone Number(Required)

Secondary Phone Number

Primary Disability/Diagnosis(Required)

Parent/Guardian Name(Required)

First Last

Parent/Guardian Email(Required)

Parent/Guardian Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian Home Number(Required)

Parent/Guardian Work Number

Emergency Contact Name(Required)

First Last

Emergency Contact Phone Number(Required)

Case Worker's Name

First Last

Caseworker's Phone Number

Authorization for Emergency Medical Treatment

By signing my name, I authorize CUSR to arrange for emergency medical treatment, in the event of an injury to my child, or me, and in the event that I or my designated emergency contact cannot be reached by CUSR.

Date of Authorization(Required)

Month

Day

Year

On this date, I authorize CUSR to arrange for emergency medical treatment, in the event of an injury to my child, or me, and in the event that I or my designated emergency contact cannot be reached by CUSR.

Medical Information

Preferred Hospital(Required)

Doctor's Name(Required)

Doctor's Phone Number

Medications

Medication

Dosage

Frequency

Please list all medications the participant is taking, even if it will not be dispensed during program. A medication dispensing form must be obtained, signed, and returned to CUSR in order for staff to assist with dispensing.

Does the Participant Self-Medicate?

Yes

Does the Participant Need a Reminder to Take Medication?

Yes

Does the Participant Have Any Allergies?(Required)

Yes

If Yes, Please Explain:(Required)

Is the Participant Subject to Seizures?(Required)

Yes

If Yes, Please List the Duration, Frequency, and Date of Last Seizure(Required)

Are Seizures Controlled by Medication?

Yes

What might trigger a seizure in the participant?

Are there any warnings and/or behavior changes before the seizure occurs?

Yes

If yes, please explain:(Required)

What basic first aid procedures should be taken when your child has a seizure?

Please describe what constitutes an emergency for your child?

When should staff contact Emergency Medical Personnel/911 during a seizure?

Are there any doctor’s restrictions?(Required)

Yes

If yes, please explain:(Required)

If participant has Down’s Syndrome, have x-rays of the C-1 and C-2 vertebrae been taken and examined?(Required)

Yes

Not Applicable

Is participant clear of Atlanto Axial Subluxation?(Required)

Yes

Not Applicable

Does participant have any temperature sensitivity we should be aware of?

Feeding Information

Check all applicable:

Feeding Information(Required)

Participant eats independently. No assistance needed.

Participant needs physical assistance with feeding.

Participant has a preference of which side of the mouth to be fed.

Right

Left

Center

No preference

Describe how the participant takes liquids:(Required)

Specific instructions regarding feeding:

Toileting and Changing

Check all applicable:

Toileting and Changing(Required)

Uses toilet independently.

Uses toilet, needs assistance.

Uses toilet, but wears diapers.

Uses diaper only.

Describe frequency required for changing and/or toileting :(Required)

How is the need for bathroom communicated?(Required)

Specific instructions regarding toileting and changing:(Required)

Medical Questionnaire

Does participant use any of the following:

Hearing Aid(s)(Required)

Yes

Sometimes

Corrective Eyewear(Required)

Yes

Sometimes

Orthopedic or Prosthetic Devices(Required)

Yes

Sometimes

Manual Wheelchair(Required)

Yes

Sometimes

Electric Wheelchair(Required)

Yes

Sometimes

Walker(Required)

Yes

Sometimes

Cane(Required)

Yes

Sometimes

Braces (AFOS, SMOS, etc.?)(Required)

Yes

Sometimes

FOR INDIVIDUALS WHO USE AMBULATORY ASSISTANCE, TRANSFER ASSISTANCE, AND/OR USE WHEELCHAIRS

Can participant do assisted or independent walking?

Yes

If yes, how much or how often?(Required)

What are your instructions regarding wheelchair straps (foot straps, chest straps etc.)? For example are chest straps only for bus rides?

Please check the amount of staff assistance necessary when conducting a transfer:

Independent. No assistance necessary.

Stand-by or supervision. May be potential for loss of balance. Gait belt necessary.

Contact Guard Assistance. One person, hands on.

Transfer with one person. Minimal assistance. Participant can bear weight. Gait belt necessary.

Transfer with one person. Maximum assistance. Participant cannot bear weight. Gait belt necessary.

Transfer with two people needed.

Specific instructions regarding transfers:

How much time out of the wheelchair should participant spend? This may not always happen but we will try to accommodate.

If pool entry requires transfer assistance from a wheelchair, please describe the process:

Communication

Is the participant capable of giving staff instruction (examples include food requests, personal care information) or should staff rely on parent/guardian comments only?

How does the participant communicate? (verbally, sign, directional movement with eyes, picture choices, etc.)

Characteristics of the participant: (silly, quiet, laughing, etc.):

Recreation Information

Can participant swim independently?(Required)

Yes

Sometimes

Does participant use a floating device while in water?(Required)

Yes

Sometimes

Does participant need 1:1 supervision in water?(Required)

Yes

Sometimes

Describe locker room supervision/ability to keep track of own belongings:

Is participant able to stay with a group?(Required)

Yes

Sometimes

Can participant get home without supervision (walk, public transportation, etc)?(Required)

Yes

Does the participant have any preferred activities or interests that you can briefly describe?

Daily Living Skills/Communication/Behavior Information

Does the participant require assistance with any of the following?

Eating/Drinking(Required)

Yes

Sometimes

Toileting(Required)

Yes

Sometimes

Dressing/Undressing/Tying Shoes(Required)

Yes

Sometimes

Money Handling(Required)

Yes

Sometimes

Following Directions(Required)

Yes

Sometimes

Orientation to people, place, time(Required)

Yes

Sometimes

Anticipation of safety needs(Required)

Yes

Sometimes

Reading(Required)

Yes

Sometimes

Writing(Required)

Yes

Sometimes

Communication(Required)

Yes

Sometimes

Check any communication tools that the participant uses:

American Sign Language

Communication Board/Book

Personal Signs/Gestures

Please describe below any information needed to assist with Daily Living Skills.

Please list any signs of overstimulation and beneficial behavior management techniques to use:(Required)

This information, once completed, will be reviewed by CUSR Program Manager. If plan is not approved, the family and/or participant will be contacted to develop a new plan with CUSR. Once approved, his form will be added to the participants information file (PIF) and kept for one year

Parent/Guardian Signature(Required)

Date(Required)

MM slash DD slash YYYY

CAPTCHA

CUSR Explorers

Annual Information Form (Online)

CUSR Annual Information Form (AIF)

CUSR Confidentiality Statement

Authorization for Emergency Medical Treatment

Medical Information

Feeding Information

Toileting and Changing

Medical Questionnaire

FOR INDIVIDUALS WHO USE AMBULATORY ASSISTANCE, TRANSFER ASSISTANCE, AND/OR USE WHEELCHAIRS

Communication

Recreation Information

Daily Living Skills/Communication/Behavior Information

This information, once completed, will be reviewed by CUSR Program Manager. If plan is not approved, the family and/or participant will be contacted to develop a new plan with CUSR. Once approved, his form will be added to the participants information file (PIF) and kept for one year

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Contact Info

Help CUSR with Our Mission

Site Map

CUSR Explorers

CUSR Annual Information Form (AIF)

CUSR Confidentiality Statement

Authorization for Emergency Medical Treatment

Medical Information

Feeding Information

Toileting and Changing

Medical Questionnaire

FOR INDIVIDUALS WHO USE AMBULATORY ASSISTANCE, TRANSFER ASSISTANCE, AND/OR USE WHEELCHAIRS

Communication

Recreation Information

Daily Living Skills/Communication/Behavior Information

This information, once completed, will be reviewed by CUSR Program Manager. If plan is not approved, the family and/or participant will be contacted to develop a new plan with CUSR. Once approved, his form will be added to the participants information file (PIF) and kept for one year

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