Appendix P: Participant Emergency and Personal Care Information

DO-IT Scholar Emergency and Personal Care Information

Emergency Information

Should an emergency arise, DO-IT Summer Study staff will contact parents immediately. However, should we be unable to reach you, we would like the name and phone number of an alternative contact person and your child's physician.

Please complete the following:

Name of Scholar:______________________ Name of Parent/Guardian:_______________

Home Phone(s):_______________________ Work Phone(s):_________________________

Alternative Contact Name(s): __________________________________________________

Home Phone(s):_______________________ Work Phone(s):_________________________

Name of Physician(s): _________________________________________________________

Phone(s): ____________________________________________________________________

Please describe below any pertinent medical conditions, allergies, considerations, or situations that may require special attention, and include a list of medications that are prescribed for this student. Also indicate other dietary restrictions, special accommodations, or general concerns of which we should be aware. If you need additional space, please attach a separate sheet.

Personal Care

DO-IT staff cannot take responsibility for personal care. The participant's family must provide a personal care assistant if the participant needs assistance with:

  • completing morning/evening personal activities (e.g., getting out of bed, dressing, brushing teeth/hair)
  • eating
  • using the restroom
  • administering medication
  • transferring

Will your child require a personal care assistant during the Summer Study program?

Yes__ No __ If yes, please provide the following information about this assistant:

Name: ____________________________________ Telephone: _______________________

Address: ____________________________________________________________________