Terms & Regulations

Sprout 893 Amsterdam Avenue New York, NY 10025-4403
212-222-9575 fax: 212-222-9768 e-mail: vacations@GoSprout.org

• Please clearly print all of the information requested on the four sides of this form.
• The information you provide allows us to best serve the trip participant and assures that
their needs can be accommodated properly.
• Please contact us if you have any questions in filling out this form.

Medical Information

Medical Insurance: (please circle)MedicaidMedicareNumber:_______

Other Insurance (if any) Company:__________________________ Policy #:_________

MEDICATIONS INFORMATION - We understand that medications often change over the course of time and can sometimes change the day before a trip leaves. However, please answer the following questions to give us an idea of the attention to medications that the applicant will require. Exact medication information including meds, times and dosage must be presented to trip staff at the start of each trip

Does the applicant generally take medications:yesno

Is the applicant able to self-administer his/her own medications?yesnosome

How many different meds does the applicant generally take? 1-23-45 or more

How many times per day does the applicant generally receive meds? 1-23-45 or more

Does the applicant generally take medications that require the monitoring of blood pressure, blood sugar or other bodily functions.yesno

If yes please describe what needs to be monitored: ___________________________

Please list any known allergies:_____________________________________________

Does the applicant have seizures?yesno

If yes, please list type and general frequency:_________________________________

Does the applicant have hepatitis?yesnoIf yes, what type:_____________

Is the applicant overly sensitive to the sun due to medication or other condition? yes no

Please comment on any physical limitations the applicant may have:

_______________________________________________________________________

_______________________________________________________________________

Please list any dietary restrictions: _________________________________________

_______________________________________________________________________

_______________________________________________________________________

At times during our trips, we allow our participants to have one alcoholic beverage with dinner. Is the applicant allowed to have an alcoholic beverage? _yes__ no

Please comment on any additional medical information that we should know about:

_______________________________________________________________________

Behavioral Profile

Applicant's name:________________________________________________________

Contact Person:__________________________________ Phone:_________________

Please describe the applicant's general behavior and social abilities:

______________________________________________________________________

Please describe the applicant's communication skills? (If applicant is non-verbal, to what extent can the applicant make his/her needs known?)

______________________________________________________________________

What are some of the difficulties that the applicant may encounter during the trip?

______________________________________________________________________

Please comment on the applicant's ability to stay with a group. (Does the applicant have a tendency to wander? Is the applicant easily distracted by other sights when moving with a group? Will the applicant walk away from a group on his/her own?)

______________________________________________________________________

Additional comments:

______________________________________________________________________

ADL Skills

• Please circle the choice for each category that best describes the applicant's ADL skills.
• Please provide any information related to the completion of the task in each category.

Using toiletfully independentneeds promptingneeds assistancefully dependent