Jacob’s Ladder Pediatric Rehab: JL Academy Intake Packet – Page 1 of 4
JL Academy
Child’s Name #1 ________________________ Age _______ Birth Date ___________
Sex: M
F
Diagnosis/Disability: ___________________________________________________________________
Child’s Name #2 ________________________ Age _______ Birth Date ___________
Sex: M
F
Diagnosis/Disability: ___________________________________________________________________
Emergency Contact #1: ___________________________ Relationship to Child: ____________________
Home Address: _____________________________ City: __________________ State :____ Zip: _______
Home Phone: ________________ Cell Phone: ____________________ Email: ______________________
Employer: _____________________ Address: _______________________ Phone: __________________
Emergency Contact #2: ___________________________ Relationship to Child: ____________________
Home Address: _____________________________ City: __________________ State :____ Zip: _______
Home Phone: ________________ Cell Phone: ____________________ Email: ______________________
Employer: _____________________ Address: _______________________ Phone: __________________
Child’s Physician: _____________________________ Phone Number: ___________________________
Waiver of participation and release of liability:
As a condition of participation in the program, I waive any and all claims against Jacob’s Ladder Pediatric Rehab
Center, its affiliates and/or agents for injury or damage that may be sustained as a direct or indirect result of my
child’s participation in program activities. _________ Initial
I give my consent to his/her being administered any emergency medical treatment by a physician or hospital in case of
an accident or illness. ___________ Initial
By signing below, I am acknowledging that I have read and understand the policies, general information, and Liability
Waiver outlined above.
Parent/Guardian Signature __________________________________
Date: ____________________
Jacob’s Ladder Pediatric Rehab Center – Updated August 2015
Jacob’s Ladder Pediatric Rehab: JL Academy Intake Packet – Page 2 of 4
Please Complete One for Each Participating Child
Child’s Name: ____________________________________________________________
1. List any food allergies:
________________________________________________________________________
2. List any medication allergies:
_________________________________________________________________________
3. List any other allergies:
_________________________________________________________________________
4. List any medical conditions our staff should be aware of:
_________________________________________________________________________
5. Does your child have Epilepsy/Seizures:
☐Yes
☐No
6. Does your child carry or need an epi-pen for an allergy?: ☐ Yes ☐No
If yes, I give my permission for Jacob’s Ladder staff to administer Epi-Pen _________ Initial
7. List any medications your child is currently taking:
_________________________________________________________________________
8. Use the following key for grading level of supervision required for each task listed:
I = Independent
S = Some Supervision C = Constant SupervisionP = Physical Assist
____ Diaper
____Toileting
____Feeding
____Medication
9. Briefly describe any behavioral issues or special care for your child our staff should be aware of:
____________________________________________________________________________
10. List foods that should be avoided: ________________________________________________
11. List food preferences: _________________________________________________________
I consent to Jacob’s Ladder Pediatric Rehab Center to provide JL Academy services to my child, which may include gross & fine
motor activities, sensory program activities, group social activities, meal prep activities, quiet times and participation in snack and
lunch time activities:
Parent/Guardian Signature: ______________________________
Date: ______________
Jacob’s Ladder Pediatric Rehab Center – Updated August 2015
Jacob’s Ladder Pediatric Rehab: JL Academy Intake Packet – Page 3 of 4
It is the policy of Jacob’s Ladder Pediatric Rehabilitation Center, Inc. to consider all patients/customers without regard to race,
color, religion, gender, national origin, age, or mental or physical disability. Information obtained regarding any of these
characteristics will be recorded solely for informational purposes, and will be considered only as required to determine the type
and level of care to be provided.
Answer YES (Y) if your child has a current illness or history of the following, otherwise answer NO (N)
AIDS
Allergy
Asthma
Balance
Problems
Chicken Pox
Coordination
Problems
Seizures
Diabetes
Difficulty
Concentrating
Injuries to Head
Y
Y
Y
Y
N
N
N
N
Y N
Y N
Y N
Y N
Y N
Y N
Eating Problems
Epilepsy/Seizures
Extreme tiredness
Operations
Eye Problems
Fainting Spells
German Measles
Heart Disease
Hepatitis
Fever
High Blood Pressure
Hospitalizations
Ear Problems
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
Loss of consciousness
Measles
Mumps
Dizziness
Paralysis
Rheumatic Fever
Sensory Integration
Problems
Tuberculosis
Whooping Cough
Jaundice
Cancer
Other (please explain)
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
N
N
N
N
N
If you marked any of the above as YES, please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
When would you like your child to participate in our JL Academy?
2-Day Option:
Tu, Th
$30/week per child
3-Day Option:
M, W, F
$45/week per child
5-Day Option:
M–F
$75/week per child
Enrollment is not complete until the upcoming month is paid in full.
Invoice and payment must be received 5 days prior to upcoming month.
Scholarship available for families who need financial assistance.
Contact us for more information: info@jacobskids.org or 219-764-4888
By signing below, I
verify that all of the information on the Jacob’s Ladder intake
packet is complete and accurate. I also understand that I will pay on a monthly basis, to be collected at the
first session of each month, and I will not be reimbursed for any sessions I miss.
___________________________________________________
Parent/Responsible Party Signature
___________________________
Date
Jacob’s Ladder Pediatric Rehab Center – Updated August 2015
Jacob’s Ladder Pediatric Rehab: JL Academy Intake Packet – Page 4 of 4
Photograph/Media Authorization
________ I authorize Jacob’s Ladder Pediatric Rehab Center to photograph my
child(ren).
I give permission for my child to be included in picture/video recording that may be
used on our brochures, newsletters, Donor “Thank You”s, and Jacob’s Ladder’s
Website.
________ I DO NOT authorize Jacob’s Ladder Pediatric Rehab center to photograph
my child(ren).
_______________________________________________
Child’s Name
____________________________________________
Parent/ Guardian Signature
__________________
Date
Jacob’s Ladder Pediatric Rehab Center – Updated August 2015