Please Complete in Full Name: _____________________________________________Please Complete in Full Seizures YES ❑ NO ❑ Check those which apply and explain below if necessary: Specify: ❑ No problems or unusual behavior ❑ Makes choices Type ______________________________________________________________ Y ❑ Is cooperative ❑ Follows directions o ❑ ❑ ur People and Places Shy/withdrawn/keeps to self Talkative Frequency: _________________________________________________________ ct Us ❑ Fabricates stories ❑ Talks to anyone Vaca nta Medication: ________________________________________________________ tion Co ❑ Needs coaxing into activities ❑ Wanders *explain ❑ Has history of stealing/may steal ❑ Teases others Dietary Limitations/Restrictions YES ❑ NO ❑ Please comment, explain or add any behaviors not covered. If you have a Describe: __________________________________________________________ Gift Behavior Program Plan, please attach. *Required. Activity Limitations/Restrictions YES ❑ NO ❑ _______________________________________________________________________ Your People and Places Vacation! Describe: __________________________________________________________ Certificates _______________________________________________________________________ ❑ ❑ Join us on the fun and exciting vacation of your choice! Do you have any specific fears? YES ❑ NO ❑ Does applicant accurately report illness and health concerns? YES NO Available Explain fear and how it’s usually handled: _______________________________ Describe: __________________________________________________________ ❑ ❑ AS ALWAYS: ___________________________________________________________________ MEDICATION YES NO What types of situations provoke anger or frustration? Describe frequency: Travel in a small group so we can individualize your vacation based on your needs and If you are taking medication it is required to attach medication administration records interests: 6 to 8 vacationers travel with 2 People and Places professional tour escorts who _______________________________________________________________________ or list of both prescription and non prescription medication. are experienced with assisting people who have special needs. Talk to Them before your ❑ ❑ ❑ trip! _______________________________________________________________________ Please check: Independent Needs Supervision Specify below supervision needed tear here Explain how you express anger and/or frustration and how it is usually handled: Choose from lots of exciting and diverse vacation destinations. _______________________________________________________________________ Stay at wonderful, quality hotels, resorts, and bed-and-breakfasts. _______________________________________________________________________ Receive suitcase tags and great travel tips from your People and Places Traveler’s Guide. _______________________________________________________________________ Please note or attach any other relevant medical information about the applicant: Enjoy your vacation memories with your special People and Places Keepsake Photo ACTIVITIES OF DAILY LIVING: (Please check and detail as requested) _______________________________________________________________________ Album. Specify Self-Care Totally Needs Support Bowel or Incontinence issues YES ❑ NO ❑ IN ADDITION: Skills: Independent Assistance Poor Required Dressing _____________ _____________ _____________ _____________ Explain: ________________________________________________________________ Receive a complimentary People and Places Keepsake as our gift to you. Bathing _____________ _____________ _____________ _____________ Toileting _____________ _____________ _____________ _____________ SOCIAL/BEHAVIORAL: Win free trips! Hygiene _____________ _____________ _____________ _____________ Does applicant interact appropriately with: Receive our Newsletter to bring you the joy of travel memories year-round. Be a reporter Feeding _____________ _____________ _____________ _____________ Staff YES ❑ NO ❑ for us!! Give the Gift of Travel ~ a People and Places Gift Certificate! Skills: ❑ ❑ Money _____________ _____________ _____________ _____________ Peers YES NO Join us for a wonderful vacation! Holidays, Birthdays, Special Occasions! Wondering about a unique gift for Reading _____________ _____________ _____________ _____________ Strangers YES ❑ NO ❑ someone special? Travel brings memories for a lifetime ~ give the gift of Writing _____________ _____________ _____________ _____________ travel on a People and Places Vacation! Applicant is able to safely and respectfully share a hotel room with another Telling Time _____________ _____________ _____________ _____________ vacationer YES ❑ NO ❑ Would you like more than the Gift Certificate? Personalized, specially Please provide any further information which will assist us in knowing your needs for If no, please explain: _________________________________________________ designed, travel gift baskets are also available! Just contact us, and we’ll initial placement on a vacation. Upon acceptance, supplementary information will be create one you’ll love! requested to further assist the vacation staff in providing a safe and enjoyable experi- ___________________________________________________________________ 2 ence for you. How many?_____________ How yes). if (check possible if trip one than more like Would ❑ – Arthur C. Clark C. Arthur – 1 Third Choice: ___________________________________________________________ Choice: Third __________________________________________________________________ Second Choice: _________________________________________________________ Choice: Second go beyond them into the impossible.” the into them beyond go __________________________________________________________________ First Choice: ____________________________________________________________ Choice: First the limits of the possible is to is possible the of limits the Check if you need a slower paced trip paced slower a need you if Check ___________________________________________________________________ ❑ ❑ “The only way to discover to way only “The VACATION CHOICES: VACATION ___________________________________________________________________ – Aldous Huxley Aldous – Check to receive updates by email by updates receive to Check ❑ ❑ pcf lege:(nld netbts od t)__________________________ etc) food, bites, insect (Include Allergies: Specify Email: _________________________________________________________________ Email: happens to him.” to happens NO NO YES Allergies ❑ ❑ Phone: ( ) _______________________ Cell Phone: _____________________ Phone: Cell ( _______________________ Phone: ) man; it is what man does with what with does man what is it man; MEDICAL: Name _________________________________________________________________ Name “Experience is not what happens to a to happens what not is “Experience Individual Responsible for Assisting Applicant with Vacation Preparation Vacation with Applicant Assisting for Responsible Individual If not, explain communication system: ___________________________________ system: communication explain not, If Referring Individual Only Individual Referring Only Applicant or Chief Seattle, Dwamish tribe, 1853 tribe, Dwamish Seattle, Chief ↔ ↔ NO NO YES speaking? when understandable applicant Is ❑ ❑ Mail Information to: (please circle one) circle (please to: Information Mail himself.” Phone: ( ) _______________________ Cell Phone: _____________________ Phone: Cell ( _______________________ Phone: ) ___________________________________________________________________ Whatever he does to the web, he does to does he web, the to does he Whatever City: _______________________ State: ________________ Zip: ________________ Zip: ________________ State: _______________________ City: Describe any sign language used: _______________________________________ used: language sign any Describe web of life. He is merely a strand in it. in strand a merely is He life. of web Address: _______________________________________________________________ Address: belongs to the Earth. Man did not weave the weave not did Man Earth. the to belongs NO NO YES impaired? hearing applicant Is ❑ ❑ Name(and Agency if applicable) ___________________________________________ applicable) if Agency Name(and “The Earth does not belong to man. Man man. to belong not does Earth “The REFERRING INDIVIDUAL Completing Application Completing INDIVIDUAL REFERRING (if other than applicant) than other (if Describe ___________________________________________________________ Describe No No Yes vacation? Places and People a on been ever you Have NO NO YES impaired? visually applicant Is a David Neel David a ❑ ❑ ❑ ❑ — Epitaph of Alexandr of Epitaph — Other School Activities Hab/Work Day ❑ ❑ ❑ Indicate mobility assistance needed: _____________________________________ needed: assistance mobility Indicate but gives strength to the spirit.” the to strength gives but Day Treatment Day Employment ❑ ❑ Type of Daily Setting (check): Setting Daily of Type “Travel not only stirs the blood, the stirs only not “Travel NO NO gait? YES unsteady or pace slow at walk applicant Does ❑ ❑ Length of time at your current residence: ____________________________________ residence: current your at time of Length NO NO YES ambulatory? fully applicant Is ❑ ❑ Independent Living Independent __________________ type) (specify Apartment ❑ ❑ Other disabilities: ____________________________________________________ disabilities: Other you stop playing.” stop you Community Residence/IRA Community ICF