Motor Activity Clinic Online Registration

Client First Name

Client Last Name

Street Address

City

State

Zip Code

Parent's Last Name

Parent's First Name

E-mail

Home Phone Number

Cell Phone

Date of Birth

Age (years)

Race

Gender

Name

Relation to Child

Emergency Contact Phone Number

Diagnosis/ Current Level of Function

Is client prone to having seizures?

If yes, please indicate what type and how often:

Medications/ taken for/ side effects

Current language skills or expressive skills:

Current interests and hobbies:

Dislikes and Special Concerns:

Behavioral Characteristics the child exhibits include: (Select all that apply)

If others, please describe:

Select specific areas of concern you have for your child's development (Please select only 2):

If others please describe:

If others, please describe:

If Others, please describe:

Helpful Instructional Strategies (Select all that apply)

If Others, plese describe

Suggestions for Successful Participation (Select all that apply)

If Others, please describe:

Motor behavior currently demonstratd by individual (Select all that Apply)

If others, please describe:

Length of activity time tolerated by individual

Please provide any other pertinent information regarding the clients motor abilities

Please let us know what type of student you believe would work best with your child:

List three things that your child has recently accomplished.

Choose one of your child's most recent accomplishments and describe what helped him/ her learn this.

What are three things that your child is working to learn now?

What is your child learning now that is causing him/her trouble learning this new skill?

What is one thing you would like your child to learn in the next six months?

Is there any additional information about your child that would help us in our teaching?
(For example, what skills would you like your child to work on during the Motor Activity Clinic?)

Client Name:

Parent Name:

Phone Number

Email Address:

Anticipated Missed Clinic Dates

Client's T-Shirt Size

Explanation for Participation & Evaluation
Your son/daughter/guardian will be asked to perform certain procedures and tasks which will aid in the evaluation of fundamental motor skill, fitness, and swimming skills. This may include all or part of the following: weight, percent body fat, resting blood pressure, and measurements for flexibility and muscular strength, endurance measures, and skill testing. In some cases, your son/daughter/guardian will be asked to begin a certain work level and progress until he/she can no longer perform the test. Although he/she will be encouraged to perform to their best ability, we do not wish for anyone to perform these tests at a level which is abnormally uncomfortable. At any time, that all or any portion of the procedures described above may be terminated without penalty.

Risks and Discomforts
There exists the possibility of certain changes to occur during the tests and activities. They include abnormal blood pressure, fainting, disorders of heart beat, and in very rare instances, injury. Every effort will be made to minimize these by the preliminary screening and by observations during testing and activities. Emergency equipment and trained personnel are available to deal with these situations should they happen.

Benefits to be expected from participation
Many benefits may occur from your son/daughter/guardian's participation including: increased cardio respiratory capacity, improved skill level, opportunities for social interaction and enhancement, and incidental improvements from participation. Additionally, the clinic also provides parents/guardians to observe the activities and benefit from this observation.

Confidentiality
The information which is obtained during the laboratory evaluation of the Motor Activity Clinic will be treated as privileged and confidential and will not be released without your consent. The information obtained, however, may be used for statistical or scientific purpose with your right to privacy retained. In addition, we asked that we be allowed to videotape and photograph your son/daughter/guardian for instructional purposes. Your consent will be asked for any other use of the videotapes and/or pictures (e.g., University programs).

Freedom of Consent
If you have any doubts or questions, please do not hesitate to ask. Permission for your son/daughter/guardian's participation is voluntary. You are free to deny consent if you so desire or withdraw at any time.

I have read this form and understand the test procedures to be performed.

I consent to participate in the program.

IUPUI Adapted Movement Programs (AMP) have many exciting programs we would like to be able to share with the community via social media (Facebook, Instagram, Twitter). In order to do so, there will be times when we may need to take pictures of your child at during participation in clinic.

If you do not wish for your child to be photographed or video-taped during these clinics for social media purposes of the AMP program promotion, please select NO so that we can retain this for our records.