Healthcare Activity Specialist Form

Healthcare Activity Specialist Form

Participant Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History & Functional Status

Mobility:    Uses Assistive Device(s):

Cognitive Status / Behavioral Considerations:

Activity Participation & Preferences

Requires Assistance for Activities: Yes No

Transportation & Supervision

Transportation Provided: Yes No

Authorizations, Risks & Privacy

I authorize participation in scheduled activities designed by the Activity Specialist. I understand that while activities are planned to reduce risk, participation may involve physical exertion and other inherent risks including but not limited to falls, overexertion, allergic reaction, emotional distress, or contact with other participants. I acknowledge that these risks cannot be eliminated entirely.

I certify that the medical information provided on this form is accurate to the best of my knowledge. I agree to notify staff of any changes in physical or mental condition that might affect my ability to participate safely.

Consent for Emergency Treatment: In the event of an emergency during activities, I authorize staff to arrange or provide emergency medical treatment and transportation as deemed necessary. I understand I will be responsible for any related costs not covered by insurance.

Release of Liability: To the extent permitted by law, I release the provider and affiliated staff from liability for incidental injury arising from routine activity participation, except in cases of gross negligence or willful misconduct. This release does not waive statutory rights that cannot be released.

Privacy & Records: I acknowledge that information entered on this form will be maintained in my health record in accordance with applicable privacy laws. Information relevant to activity participation may be shared with clinical staff, designated caregivers, or emergency responders as necessary for safe care.

Photo/Video Release for Program Use: I authorize photos/videos for program documentation and therapeutic use, adhering to facility privacy practices. I decline authorization for photos/videos.

Right to Withdraw: I understand my participation is voluntary and I may withdraw consent to participate at any time. Withdrawal of consent for specific activities will be documented and communicated to relevant staff.

Revocation: This authorization may be revoked in writing, except to the extent that action has already been taken in reliance upon it. To revoke this authorization, submit written notice to program administration.

Authorization Effective Date:    Authorization Expiration Date:

Acknowledgment & Consent

By signing below I acknowledge that I have read and understand the statements above, that staff have had the opportunity to answer my questions, and that I consent to participate in activities under the terms set forth in this form.

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