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Registration Form_Hospital Support Program

Child's Name:: First Name:

Last Name:
Date of Birth:
Address:: Line 1:

Line 2:

City:

Country:

State:

Postal Code:
I was born in (country of birth):
My gender is:: MF
My diagnosis is:
I was referred from:
I am registered with Disability Services:
I live at home with my family:
My family take care of me all the time:
My usual hospital is:
:: My nominated contact person's details
Name:: First Name:

Last Name:
Relationship to me:
Mobile Number:
Email Address:
My siblings name/s and age/s are:
My grand parents and/or significant others:
Please list 5 support goals you would like to achieve during stays in hospital to help us support you and your family:
Any other support that myself and family may need during my stay:
To communicate effectively I need to use the following communication aids or signs:
If my needs aren't being met, I have certain ways in which I communicate this:
To get your attention I will:
You will need to be aware of certain things related to my communication:
I have difficulty with my vision:
I need to wear glasses:
I have difficulty with my hearing:
I need to wear hearing aids:: YesNo
I can drink out of a cup:
I can feed myself:
You can help me with my nutrittion and drinking by:
Other important things you need to know about my nutrition:
I am allergic to:
Reaction:
Treatment:
I have epilepsy:
The seizures that I have are called:
My seizures normally last for:
My usual seizure is like this:
When I am having a seizure can you please:
Important things to know about my mobility:
Other important things you need to know about my daily living activities:
When I am staying in hospital and well enough, I enjoy:
Outside activities I enjoy if I can go outside:
I'm not allowed to participate in these recreational activities:
Other useful information about me including my favourite toys e.g. Thomas tank, dolls, noisy toys, music, stories, etc:
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Registration Form_Hospital Support Program

My nominated contact person's details