Colorado Discover Ability · 2023-2024 Intake Form

Current Registration Year

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23-24

Contact Type

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Participant Information

Name

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First Name

Last Name

Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Participant Phone

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email address

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Verify Email

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Parent/Guardian/Caregiver/Spouse/Emergency Contact first and last name:

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If you are your own guardian, please enter your information.

Parent/Guardian/Caregiver/Spouse/Emergency Contact Phone #

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What was your first year with CDA?

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(if this is your first year, enter 2022)

Participant's Date of Birth

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(mm/dd/yyyy)

Gender

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Participant's Ethnicity

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Veteran Status

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Branch

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Rank

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What is your disability?

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Please give a short description:

What was the onset of the disability?

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Participant needs assistance for/with:

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CDA (Colorado Discover Ability) program volunteers and staff cannot administer medication or assist with the personal care of participants.

Restroom

Eating

Dressing

Behavior concerns

Medical Needs

Wandering Tendencies

All activities of daily living

None of the Above

Does the participant have a Traumatic Brain Injury?

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Does the participant have PTSD?

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PTSD Amplifiers:

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Is the participant able to walk?

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Mobility Rating - Stairs

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If the participant uses a wheelchair, are they able to transfer independently?

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Does the participant have parts of the the body that are susceptible to impact/heat/cold?

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Hands/Arms/Shoulders

Feet/Legs

Head/Face/Neck

Body

No Issues

Other

If "Other" or "Unique" allergies please explain:

Has the participant had a seizures?

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Is the participant required to carry:

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Inhaler

Oxygen

Epi-pen

Other Rescue Medications

No Rescue Medications

Please list current medications:

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Name and share if any of the medications require special handling. (If they are not required please enter None.)

Participant Height:

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Participant Weight:

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Participant Shirt Size:

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Will you be applying for Financial Assistance?

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Thank you for participating in CDA programs! This process will be completed on an annual basis beginning October 1, 2020 and will be good until September 30, 2021. Colorado Discover Ability (CDA) is a non-profit organization and has limits on funding available for financial assistance. We strongly encourage participants to pay as much as they are able so that assistance will be available to others throughout the year. Our financial assistance is now provided on a sliding scale based on income.

If you answered yes for financial assistance:

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There is additional information required to receive Financial Assistance: Please tell us what works best for you.

Case Worker Name & Contact

2023-2024 Intake Form - Participant

Participant Information