Sensory Friendly Santa-Intake Form

Participant Name *

First

Last

Address *

Address Line 1

Address Line 2

City

Province

Postal Code

Phone *

Email *

Date of Birth *

Is participant a 'flight risk'? *

Is the participant verbal? *

Sensory Needs: Please indicate whether the participant is hypo/hyper sensitive to the following types of stimuli. Please provide details and/or examples when applicable. Tactile, Auditory, Smell, Movement, Visual (including lighting). *

How would you describe the participant's temperament? Please check all that apply: *

If "other", please describe:

If the participant has any fears or aversions, please describe (if none, please write N/A):

What is helpful for holding their attention?

Birth participant in

What are the triggers for outbursts or meltdowns (i.e. loud noises, being touched, transition without warning, etc.)?

Does the participant have any special interests that may be helpful for staff to know in advance? Please describe.

Is there anything else you would like us to know about the participant?