Social Engagement Participant Bio "*" indicates required fields Step 1 of 4 25% 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 RelationshipSecondary Caregiver? * Required Yes No Secondary Caregiver (SC) * Required SC First Name SC Last Name SC Email * Required SC Phone * RequiredSC 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 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.
