Contact Information

 

Dr. Kandice Porter

Department Chair

kporte21@kennesaw.edu

470-578-6216

FAX 470-578-6561

 

 

Department of Health Promotion

and Physical Education

Kennesaw State University

Convocation Center

Mail Drop 0202

1000 Chastain Road

Kennesaw, GA 30144-5591

 

 

Physical and Leisure Activities for Youth (PLAY)
Enrollment Questionnaire

The PLAY provides physical and motor developmental activities for persons with special needs.  There are opportunities for development and/or improvement in the following areas:  (1) developmental gross motor skills, (2) perceptual- motor skills, (3) swimming and water safety skills, (4) play/social skills, (5)  dance and creative movement, (6) physical fitness, and (7) life-time sport/ recreational pursuits.

 

It is necessary to have the following information in order to plan an individualized physical activity plan that meets the needs of your son/ daughter/ward.  Please complete and return the forms as soon as possible.  All participants must have these forms on file prior to entering the PLAY.  If you have any questions/concerns, please contact the program director.

 

 

Demographic Data:

 

Participant's Last Name:

Participant's First Name:

 

 

Sex:

Date of Birth:

Phone #:

Male Female

Home Address (Street Address):

City:

State:

ZIP code:

 

Parent/Guardian's Last Name:

Parent/Guardian's First Name:

 

 

Home Phone #:

Work Phone #:

 

 

Parent/Guardian's Address (If different from above):

City:

State:

ZIP code:

Parent/Guardian's Email Address:

 

School/Training Program Attended by Participant

Address (Street):

City:

State:

ZIP code:

School/Training Program Contat

Position of Contact

 

 

 

 

Disability/Impairment (check all that apply):

 

No Disability/Impairment

Asthma

Autism

Cardiovascular Problem

Cystic Fibrosis

Developmental Delay

Diabetes

Emotional/Behavioral Disorder

Epilepsy

Learning Disabled

Multiple Sclerosis

Muscular Dystrophy

Obesity

Spina Bifida

Spinal Injury

Subject to Seizures

Other - specify:

   

Auditory Impairment (select one):

Deaf Hard of Hearing

Visual Impairment (select one):

Blind Partially Sighted

Cerebral Palsy (select one):

Mild Moderate Severe

Mental Retardation (select one):

Mild Moderate Severe Down Syndrome

 

 

Behavioral Characteristics (check all that apply):

 

Aggresive

Cooperative/calm

Cooperative with Peers

Cooperative with Teachers

Self-Abusive

Self-Stimulatory

Subject to Physical Outbursts

Wanders/Runs Away

Withdrawn

Other - specify:

 

 

Methods of Communication (check all that apply):

 

Verbal

Uses Finger Spelling

Able to Follow Simple Verbal Directions

Non-Verbal

Uses word board

Able to Follow Complex (3-4 step) Verbal Directions

Uses Sign

Other - specify:

 

 

General Information

 

Is participant on medication?

If yes, please describe:

 

Yes No

 

     

Purpose of medication:

Control Seizures

Control Hyperactivity

 

Depression

Control Aggressive Behavior

 

Other, please specify:

     

Are specific behavior management techniques used with participant?

If yes, please describe:

Yes No

 

 

 

Please list any specific behavior problems:

 

 

 

Is participant toilet trained:   

Occasional Accidents?:

 

Yes No    

Yes No

 

 

 

 

Has participant been involved in previous physical education/motor development/recreation/sports programs?:

 

Yes No

 

If yes, please indicate which type of program(s):

School

Community

Other, please specify:

 

 

Special Equipment used (check all that apply)

 

Manual Wheelchair

Electric Wheelchair

Protective Helmet

Braces, please indicate location:

Prosthesis, please indicate location:

Tubes/shunts of any type, please specify:

Walker, please indicate type:

Hearing aid (ear)

Hearing aid (body pack)

Corrective eye glasses

Other, please specify:

 

 

Transportation

 

Provided by...

 

Parent/Guardian

Residential Agency:

Friend:

Other:

 

 

Car pool, specify with whom (driver & participants):

Approximate round trip mileage to and from KSU (miles):

 

 

Signature of person completing this form:

Relationship to participant:

 

NOTE: This form MUST be returned prior to student being admitted to program.