Athlete Background Info – Rise Fitness | Inclusive Fitness Program

Please complete the following form with as much information as possible. All of the below information is kept private and not shared with anyone outside of Rise Fitness coaching staff without prior permission from a parent or guardian.

Athlete Background Information

First Name

Last Name

Athlete’s DOB

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

Athlete’s Address (Please specify if different than parent/guardian’s address)

Medical History (Please provide as accurate info as possible)

What is the athlete’s primary diagnosis?

Is there any history of seizures? If so, please describe.

Has the athlete been treated by a physical or occupational therapist? If so, please provide details.

Are there any other medical issues or details that would be important to share?

Does the athlete have a history of maladaptive behavior including aggression, self-injurious behavior? If yes, please describe. If no, please type “no.”

Is there currently a behavior treatment plan in effect for the athlete?

If yes, please describe the behavior and the current treatment plan.

Are there any repetitive behaviors including, but not limited to, physical or vocal stereotypy, rigidity of schedule/activities, or fixation on topics? Please describe.

What are the known reinforcers for the athlete? What do they really enjoy doing or request frequently?

If non-verbal or limited in expressive language, how best does the athlete communicate?

Did/does the athlete attend PE or adapted PE classes in school or extracurricular activity?

If yes, please describe, along with any IEP-related goals:

Has the athlete ever had a dedicated fitness program (individual or group)?

If yes, please describe:

Please provide a brief description of the athlete’s regular schedule. Do they attend school? Are they in a residential program? Include any vocational or extracurricular activities.

Please provide a brief description of goals you want for the athlete from participating in the RISE Fitness Kentucky programming.. It’s OK if you don’t know yet.

Is there anything else you feel we should know before getting started?