First name
Last name
Email
Mobile
1.
Name of the program you are attending:
2.
Today's Date:
3.
Does your Health Issue or allergy require a "Medical Health Care Plan" or "Mental Health Care Plan"?
4.
My medications: Please include medication that you regularly use or that you might need
5.
Gluten Free? Lactose Free? Nut Free? Kosher? Vegan? etc.
6.
Things I need to make sure I have, in order to stay happy and healthy: For example, you might need special food to manage your condition.
7.
Things that may make me worried or distressed:
8.
When I am worried or distressed you will notice that I:
9.
My support team is: You may prefer to speak to participants and your leaders, or you might prefer to seek support from friends and family.
10.
My leaders can best support me by:
11.
What are some things that you can do to manage any unexpected stress or feelings?
12.
Does anything, in particular, stand out to you as a potential challenge, make you feel uncomfortable or anxious? For example, you might need more rest time, more food throughout the day, or more time alone
13.
Is there anything else you would like to add/we should be aware of?
14.
Can you please share your emergency contact name and their mobile phone number.