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Urbana Park District
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Annual Information Form (Online)
CUSR Annual Information Form (AIF) 2022
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.
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
Home Phone Number
(Required)
Work 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)
Caseworker's Name
First
Last
Caseworker's Phone Number
Authorization for Emergency Medical Treatment
Authorization for Emergency Medical Treatment
Reset signature
Signature locked. Reset to sign again
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
Add
Remove
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
No
Does the Participant Need a Reminder to Take Medication?
Yes
No
Does the Participant Have Any Allergies?
(Required)
Yes
No
If Yes, Please Explain:
(Required)
Is the Participant Subject to Seizures?
(Required)
Yes
No
If Yes, Please List the Duration, Frequency, and Date of Last Seizure
(Required)
Are Seizures Controlled by Medication?
(Required)
Yes
No
Are there any doctor’s restrictions?
(Required)
Yes
No
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
No
Is participant clear of Atlanto Axial Subluxation?
(Required)
Yes
No
Medical Questionnaire
Does participant use any of the following:
Hearing Aid(s)
(Required)
Yes
No
Sometimes
Corrective Eyewear
(Required)
Yes
No
Sometimes
Orthopedic or Prosthetic Devices
(Required)
Yes
No
Sometimes
Manual Wheelchair
(Required)
Yes
No
Sometimes
Electric Wheelchair
(Required)
Yes
No
Sometimes
Walker
(Required)
Yes
No
Sometimes
Cane
(Required)
Yes
No
Sometimes
Does your participant need 1:1 (1 participant to 1 assigned staff)?
(Required)
Yes
No
If yes, please select reason from below
(Required)
Elopement Risk
Exhibits Physical Aggression During Outburst
Complex Medical Needs
Other
Recreation Information
Can participant swim independently?
(Required)
Yes
No
Sometimes
Does participant use a floating device while in water?
(Required)
Yes
No
Sometimes
Does participant need 1:1 supervision in water?
(Required)
Yes
No
Sometimes
Is participant able to stay with a group?
(Required)
Yes
No
Sometimes
Can participant be left alone after a program has ended to wait for a ride?
(Required)
Yes
No
Can participant get home without supervision (walk, public transportation, etc)?
(Required)
Yes
No
Daily Living Skills/Communication/Behavior Information
Does the participant require assistance with any of the following?
Eating/Drinking
(Required)
Yes
No
Sometimes
Toileting
(Required)
Yes
No
Sometimes
Dressing/Undressing/Tying Shoes
(Required)
Yes
No
Sometimes
Money Handling
(Required)
Yes
No
Sometimes
Following Directions
(Required)
Yes
No
Sometimes
Remaining appropriately clothed for the duration of the program
Yes
No
Sometimes
Orientation to people, place, time
(Required)
Yes
No
Sometimes
Anticipation of safety needs
(Required)
Yes
No
Sometimes
Reading
(Required)
Yes
No
Sometimes
Writing
(Required)
Yes
No
Sometimes
Communication
(Required)
Yes
No
Sometimes
Check any communication tools that the participant uses:
American Sign Language
Communication Board/Book
Personal Signs/Gestures
Please list any signs of overstimulation and beneficial behavior management techniques to use:
(Required)
A
A
A
