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Participant Name: ____________________________________
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Date Processed:__________
PARTICIPANT INFORMATION FORM
Demographic Information
1. Name of Participant: Click here to enter text.
2. Date of Birth (mm/dd/yyyy): Click here to enter text.
3. Gender: ☐Male ☐ Female ☐ Transgender ☐ I chose not to disclose
4. Ethnicity (select all that apply):
☐ African American ☐ American Indian/Alaskan Native ☐ Asian
☐ Caucasian
☐ Hispanic/Latino ☐ Native Hawaiian/Other Pacific Islander
☐ I chose not to disclose my ethnicity
5. Street Address: Click here to enter text.
City: Click here to enter text. State: Click here to enter text.Zip: Click here to enter text.
County of Residence: Click here to enter text.
6. Participant’s Home Phone: Click here to enter text. Cell Phone: Click here to enter text.
7. Participant’s Email: Click here to enter text.
8. What is your current living situation? (Select all that apply)
☐ I live on my own
☐ I live with family
☐ I live in a Supported Living situation
☐ I live with friends
☐ Other: Click here to enter text.
9. Emergency Contacts: Who may we contact in the event of you having health emergency
while engaged in Hussman Center programs or activities? (please provide information for two
contact persons
a. Name: Click here to enter text.
Relationship to Participant: ☐ Parent
☐ Sibling ☐ Other: Click here to enter text.
Contact Phone Number: : Click here to enter text. Email: Click here to enter text.
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Participant Name: ____________________________________
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Date Processed:__________
b. Name: Click here to enter text.
Relationship to Participant: ☐ Parent ☐ Sibling ☒ Other: Click here to enter text.
Contact Phone Number: Click here to enter text.Email: Click here to enter text.
Do we have your permission to talk with either of the emergency contact persons who
are not a legal guardian if necessary in the event of an emergency? ☐ Yes ☐ No
10. Are you your own legal guardian? ☐ Yes ☐ No
If no, please provide the following information:
Legal Guardian Name: Click here to enter text.
Relationship to Participant: ☐ Parent ☐ Sibling ☐ Other: Click here to enter text.
Contact Phone Number: Click here to enter text.
Email: Click here to enter text.
Education Information
11. Have you completed High School? ☐ Yes ☐ No
If no, expected year of graduation: Click here to enter text.
Name of High School: Click here to enter text.
If you finished high school, did you earn (check any that apply)
☐ a High School diploma? If yes, year earned Click here to enter text.
☐ a Certificate? If yes, year Click here to enter text.
☐ your GED? If yes, year Click here to enter text.
12. Have you completed a degree or certificate at a community college? ☐ Yes ☐ No
a. If yes, Name of community college
Click here to enter text.
What degree(s) did you earn? Click here to enter text.
In what area(s) of study? Click here to enter text.
When did you graduate? Click here to enter text.
When did you graduate? Click here to enter text.
b. If you have not completed a degree or certificate at a community college, are you
currently enrolled in a Community College? ☐ Yes ☐ No
If yes, Name of Community College
Click here to enter text.
On what program are you enrolled? Click here to enter text.
When do you plan to graduate?
Click here to enter text.
c. If no, do you plan to enroll? ☐ Yes ☐ No
If yes, in what program do you plan to enroll? Click here to enter text.
When do you plan to enroll? Click here to enter text.
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Participant Name: ____________________________________
Office Use Only
Date Processed:__________
d. If no, did you previously enroll in a community college? ☐ Yes ☐ No
If yes, name of Community College: Click here to enter text.
If yes, in what concentration? Click here to enter text.
In what year did you last attend? Click here to enter text.
13. Have you completed a degree or certificate at a 4 year College or University? ☒ Yes ☐No
a. If yes, Name of College or University Click here to enter text.
what degree(s) did you earn? Click here to enter text.
In what area(s) of study? Click here to enter text.
When did you graduate? Click here to enter text.
b. Are you currently enrolled in a College or University? ☐ Yes ☐ No
If yes, Name of College or University Click here to enter text.
in what program are you enrolled? Click here to enter text.
When do you plan to graduate? Click here to enter text.
c. If no, do you plan to enroll? ☐ Yes ☐ No
If yes, in what program do you plan to enroll? Click here to enter text.
When do you plan to enroll? Click here to enter text.
d. If no, did you previously enroll in a College or University? ☐ Yes ☐ No
If yes, name of College or University: Click here to enter text.
In what area(s) of study? Click here to enter text.
In what year did you last attend? Click here to enter text.
14. If you ever attended a Community College or a College or a University were you:
(check all that apply)
☐ a Full Time Student?
☐ a Part-Time Student?
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Volunteer Experience
15. Do you have any experience as a volunteer? ☐Yes ☐No
If yes, how many different volunteer positions have you had? Click here to enter text.
In the volunteer position with the most hours, about how many hours per week did you
volunteer? Click here to enter text.
Please list up to five volunteer positions that you have held and provide the following
information for each:
Volunteer position 1
Employer: Click here to enter text.
Dates: Click here to enter text.
Tasks & Responsibilities: Click here to enter text.
Reason(s) for leaving: Click here to enter text.
Volunteer position 2
Employer: Click here to enter text.
Dates: Click here to enter text.
Tasks & Responsibilities: Click here to enter text.
Reason(s) for leaving: Click here to enter text.
Volunteer position 3
Employer: Click here to enter text.
Dates: Click here to enter text.
Tasks & Responsibilities: Click here to enter text.
Reason(s) for leaving: Click here to enter text.
Volunteer position 4
Employer: Click here to enter text.
Dates: Click here to enter text.
Tasks & Responsibilities: Click here to enter text.
Reason(s) for leaving: Click here to enter text.
Volunteer position 5
Employer: Click here to enter text.
Dates: Click here to enter text.
Tasks & Responsibilities: Click here to enter text.
Reason(s) for leaving: Click here to enter text.
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Participant Name: ____________________________________
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Office Use Only
Date Processed:__________
Employment Status
16. Have you had a job position for which you received pay? ☐Yes ☐No
If yes, how many different paid work experiences have you had? Click here to enter text.
In the job with the most hours, about how many hours per week did you work? Click
here to enter text.
Please list up to five work positions that you have held and provide the following
information for each:
Work position 1
Employer: Click here to enter text.
Dates: Click here to enter text.
Tasks & Responsibilities: Click here to enter text.
Reason(s) for leaving: Click here to enter text.
Work position 2
Employer: Click here to enter text.
Dates: Click here to enter text.
Tasks & Responsibilities: Click here to enter text.
Reason(s) for leaving: Click here to enter text.
Work position 3
Employer: Click here to enter text.
Dates: Click here to enter text.
Tasks & Responsibilities: Click here to enter text.
Reason(s) for leaving: Click here to enter text.
Work position 4
Employer: Click here to enter text.
Dates: Click here to enter text.
Tasks & Responsibilities: Click here to enter text.
Reason(s) for leaving: Click here to enter text.
Work position 5
Employer: Click here to enter text.
Dates: Click here to enter text.
Tasks & Responsibilities: Click here to enter text.
Reason(s) for leaving: Click here to enter text.
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Participant Name: ____________________________________
Office Use Only
Date Processed:__________
Medical Information- Allergies/Sensitivities
17. Do you have any food/environmental allergies? ☐Yes ☐No
If yes, please check all that apply:
Food Allergens:
☐Dairy ☐Eggs ☐Fish/Shellfish ☐Gluten ☐Nuts/Peanuts ☐Soy ☐Wheat
☐Other: Click here to enter text.
Environmental Allergens:
☐Bees/Insects
☐Cigarette Smoke
☐Mold/Mildew
☐Pet Dander
☐Dust
☐Pollen
☐Grasses
☐Latex
☐Other: Click here to enter text.
18. If you are allergic/sensitive to any of these irritants, please describe your reaction: Click
here to enter text.
19. If you are allergic/sensitive to any of these irritants, do you carry an Epi-pen and/or an
Inhaler on your person? Choose an item.
Food Restrictions/Special Diets
20. Do you have any food restrictions and/or special diets at this time? ☐Yes ☐No
If you are currently on any food restrictions and/or special diets, please elaborate: Click here to
enter text.
Diagnostic Information
21. Have you ever been formally diagnosed with Autism, Asperger Syndrome, or as being on the
Autism Spectrum?
☐ Yes
☐ No
☐ Not Sure
22. Do you believe that you have Autism, Asperger Syndrome, or are on the Autism Spectrum?
☐ Yes
☐ No
☐ Not Sure
23. What term(s) do you use to describe yourself? Click here to enter text.
24. If you have been diagnosed with Autism, Asperger Syndrome, or as being on the Autism
Spectrum, please provide the following information:
Age diagnosed: Click here to enter text. Year diagnosed:Click here to enter text.
What diagnosis were you given? Click here to enter text.
Where diagnosed (Name of school/Healthcare setting): Click here to enter text.
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Participant Name: ____________________________________
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Office Use Only
Date Processed:__________
25. Please mark any and all other identified diagnoses that may influence your participation in
our programs:
☐ ADHD/Attention Disorder
☐ Anxiety
☐ Bipolar Disorder ☐ Depression
☐ Dyslexia
☐Epilepsy
☐ Hearing Impairment
☐ Language Disorder
☐ OCD
☐ Visual Impairment/Blindness ☐ OCD
☐ Learning Disability
☐ Physical Disability ☐ Other: Click here to enter text.
26. Please list any other medical/health conditions that may impact your program participation:
Click here to enter text.
27. Please list all medications you take that may have an impact in any way on your alertness, behavior,
or overall health. This information is important for us to have for planning for your participation in
Hussman Center programs and in the event of an emergency situation.
Click here to enter text.
Challenging Situations
28. What situations are most challenging for you, and what helps when these situations occur?
For example: Loud noises often scare me and cause me to withdraw from the group, it helps me
when I understand where the noise is coming from; or, I often feel excited when I meet new
people, so I will yell to show my excitement.
Please share common challenges as well as helpful prevention tips, what signs/signals you may
show when you are challenged, and what strategies you suggest we try if a challenge does
occur: Click here to enter text.
Accommodations
29. My preferred communication mode(s) are: (Check all that apply):
☐ American Sign Language (ASL) ☐ Electronic Device/Assistive Technology ☐ Gestures
☐ Picture Communication System ☐ Speech ☐ Visual ☐ Other: Click here to enter text.
30. What other supports and accommodations are helpful to you? (For example: pictures of the
activity, task steps, social stories, mobility devices, etc.) Click here to enter text.
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Participant Name: ____________________________________
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Hussman Center Experiences
31. Have you ever attended a program at the Hussman Center for Adults with Autism?
☐ Yes
☐ No
What year did you start attending programs at the Hussman Center for Adults with Autism?
Click here to enter text.
32. Please select all programs that you have participated in at the HCAA:
☐ ALPS- Adventure Communication
☐ Creative Movement
☐ Compucycle
☐ Foodies
☐ Meaningful Day
☐ Men’s Group-Friday
☐ Principle of Visual Art
☐ Well-Being Delivery
☐ ALPS- Functional Communication
☐ Cooking with Rufus
☐ Community Integration
☐ Improvisation
☐ Men’s Group-Tuesday
☐ Outdoor Adventures
☐ Rock Climbing
☐ Women’s Group-Friday
☐ Comedy Workshop
☐ Fitness Program
☐ Joy of Reading
☐ Pet Treats
☐ Yoga
33. Have you ever enrolled in the College Orientation & Life Activities program? ☐Yes ☐No
If yes, in what year? Click here to enter text.
34. Have you ever attended Social Group? ☐Yes ☐No
If yes, since what year? Click here to enter text.
Approximately how many Social Groups have you attended? Choose an item.
Your Interests And Strengths
35. Please share some interesting facts about yourself: Click here to enter text.
36. What are your strengths? Click here to enter text.
37. Please list some of your special interests and other activities you like to do for fun: Click
here to enter text.
38. What fun activities would you like to do at the Hussman Center? Click here to enter text.
Other
39. Please add anything else that you would like to share with us about yourself or your
interests and goals so that we can consider how we can best support you in having an
outstanding experience at the Hussman Center. Click here to enter text.
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