PRPH Registration Form: Fall/Winter 2019

Registration Form

Winter/Spring 2020
Participant's Name

First NameLast Name
Date of Birth

MonthDayYear
Please fill in any information that has changed since the last registration
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Group Home

YesNo
Parent/Guardian Name

First NameLast Name
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Please provide TWO numbers where you can be reached
Primary Phone Number

Area CodePhone Number
Type
Secondary Phone Number

Area CodePhone Number
Type
Emergency Contacts

Please provide TWO emergency contacts in the event that you cannot be reached.
Emergency Contact #1

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Emergency Contact #2

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Medical Authorization
Applicant's Doctor

First NameLast Name
Phone Number

Area CodePhone Number
Applicant's Hospital
Phone Number

Area CodePhone Number
This application has been completed and the information herein is correct as far as I am aware. The applicant has permission to take part in all PRPH activities, except as noted by the examining physician or me. I understand that every attempt will be made to contact me in the case of an emergency. In the event that I cannot be contacted, I give my consent to emergency x-rays, medical attention and treatments, surgery or dental care for the above mentioned participant. I also relieve PRPH, Inc. from any liability resulting from injury my child may sustain while participating in this program.
Parent/Guardian Signature
Current Date

MonthDayYear
Participation Agreement

In the event that my child becomes upset or poses a risk to the safety of others in the program, I agree that my child be removed from the program until appropriate staffing is arranged or my child’s behavior returns to a manageable level.
Parent/Guardian Signature
Current Date

MonthDayYear
Is your child enrolled in the Home/Community Based Waiver Program?

YESNO
If "yes": Child's Tabs ID#
Name of Medicaid Service Coordinator
Name of Sponsoring MSC Agency
Phone Number

Area CodePhone Number

Registration Form

Emergency Contacts

Medical Authorization

Participation Agreement

Winter/Spring 2020 Sessions

Winter Session 2020

Spring Session 2020