The Newton Wellesley Weston Committee for Community Living, Inc. Make a Donation

DROP-IN REGISTRATION


** Required Fields

PARTICIPANT INFORMATION
** First Name:
 **Last Name:
Street:
 City/Town:
State:
 Zip:
Telephone (Day):
 Telephone (Evening):
** Email:
 Date of Birth:
Social Security Number:
 Agency (if applicable):

Transportation
How is this participant transported to and from Drop-In?
If the participant takes THE RIDE,** please give phone # and I.D. # in case of a problem.
Telephone:
 I.D:
** Please note: Pick-up time should be between 8:15 p.m. and 8:30 p.m.

Emergency Contact Information
First Name:
 Last Name:
Street:
 City/Town:
State:
 Zip:
Telephone (Day):
 Telephone (Evening):
Email Address:

Special Conditions
Known allergies to food:
 Known allergies to medicine:
Does this participant have seizures:
 Yes  No		 If yes, how often?
What type?
 Date of last seizure:
If individual has a seizure, what action should be taken?

Legal Status/Guardian information
First Name:
 Last Name:
Street:
 City/town:
State:
 Zip:
Telephone (Day):
 Telephone (Evening):
Email:

N.W.W. DROP-IN MEDICATION FORM
Please note: Data provided on this form is for information purposes only. In an event of an emergency, this form will be given to medical personnel. NWW Committee is not authorized to administer any medications.
First Name:
 Last Name:
Date of Last Physical:
/ / 		Medical Diagnosis:
Primary Care Physician: Name
 Telephone:
Medication Time of Frequency Dosage