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Precautions & Contraindications
Prospective Participant Name
DOB
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Weight
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City, State, Zip Code
Doctor Name
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Behavior Concerns (i.e. elopement, aggression)
Please describe mobility level/needs. Do they require support while sitting?
Health Concerns/Diagnoses (i.e. hemophilia, seizures, Down Syndrome, implanted devices)
Is Axial Skeleton closed? (for Down Syndrome only)
Date of Last Seizure (if applicable)
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Relationship to Participant
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What outcomes are you hoping will result from time at Stir-n-Up Hope?
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