Social Engagement Participant Bio "*" indicates required fields Step 1 of 5 20% AGREEMENT IS REQUIRED FOR PARTICIPATION I have carefully read the Schmieding Center’s Release and Waiver of Liability Statement and understand it to be a release and waiver of all potential claims and causes of action for my injury or death or damage to my property that occurs while participating in programs offered by the UAMS Schmieding Center, either in-person or via technology, and it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act(s) or omission(s).Agreement is REQUIRED for participation * Required I agree CONSENT TO USE MEDIA IMAGES FOR PROMOTIONS I hereby give the University of Arkansas for Medical Sciences, their legal representative, assigns, and those acting on their behalf and with their permission, the right and permission to copyright in any part of the world, to use, reuse, publish and republish, in conjunction with my own or fictitious name, any photograph, film or video tape recording taken of me by the University of Arkansas for Medical Sciences or those acting on their behalf or with their permission, and any reproductions thereof, in any form, whether intentional or otherwise, and may be used in conjunction with any advertising material, for any purposes of trade, advertising, exhibit, publicity, or promotion, without restriction or limitations. I understand that the photographs, film and/or video may be used in news releases, newspapers or magazine articles, television, the UAMS website or social media sites (e.g., Facebook , YouTube). I hereby release, discharge, and agree to save harmless the University of Arkansas for Medical Sciences, their assigns, legal representatives, agents, and those acting on their behalf and with their permission, from and against any liability resulting from any distortion, blurring, alteration or use in composite form, whether such was intentional or otherwise, which my occur, result, or be produced in the taking of said photography, or by processing or reproduction of the finished product, its publication or the distribution of same. I waive the right to approve or inspect the recordings, advertising copy, or material used in conjunction therewith.I consent, per above terms, to the use of my image by UAMS for program and event promotion * Required Yes No Help our staff be more familiar with your loved oneParticipant DOB MM slash DD slash YYYY Type of Dementia(leave blank if unknown) Participant (PT) * Required PT First Name PT Last Name Participant Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Primary Caregiver (PC) * Required PC First Name PC Last Name PC Email * Required PC Phone * RequiredPC RelationshipEmergency Contact (EC) * Required(This should not be the same as the primary caregiver) EC First Name EC Last Name EC Email * Required EC Phone * RequiredEC Relationship HISTORYHometownParents(Separate using semicolons)Siblings(Separate using semicolons) Education(Separate by semicolons)Career(Separate using semicolons) FAMILYSpouseDeceased? Yes Anniversary MM slash DD slash YYYY Spouse DOB MM slash DD slash YYYY Children Name; Occupation; Location(Enter each on a new line) Grandchildren(Enter each on a new line) Current Pet(s)(Type, Name) INTERESTSLeisure Activities or Hobbies(Enter each on a new line) Favorite Topics or Memories(Enter each on a new line) BEHAVIORSTopics to avoidTriggers(For example: touch, loud noises, etc.) Redirection TipsMEDICALAssistive DevicesDietary RestrictionsDoes Participant need a medication reminder while attending? * Required Yes No Does Participant have a DNR in place? * Required Yes No Does Participant have a Medical Power of Attorney (POA)? * Required Yes No Upload a copy of the Participant DNR(If DNR is not available for upload, contact Lauren at 479-751-3043)Accepted file types: jpg, gif, png, pdf, rtf, doc, docx, Max. file size: 15 MB. POA NamePOA PhonePrimary PhysicianHospital of ChoiceCurrent MedicationsOther Medical Conditions(Please describe in detail)Required Acknowledgement * Required I acknowledge that, in the event of an emergency as determined by Schmieding Center staff, emergency services will be contacted by calling 911. Name First Last
