Adolescent (Ages 12-18) Member Information Please complete this form in its entirety. The information below will be utilized for data purposes only. This information helps our organization to apply for grants to continue funding our operations. Adolescent Name * First Last Preferred Pronouns * (Ex: "he, him"; "she, her"; "they, them") Date of Birth * Gender * Race / Ethnicity * Religious Preference * Parent / Guardian Contact Information Parent / Guardian Name * First Last Preferred Pronouns * (Ex: "he, him"; "she, her"; "they, them") Date of Birth * Gender * Race / Ethnicity * Religious Preference * Marital Status * Military Status * — Select — Active Duty Veteran Military Dependent Nonveteran Address * City * State * Zip Code * Email Address * Primary Phone Number * Type of Phone * — Select — Cell Home Work Secondary Phone Number * Type of Phone * — Select — Cell Home Work Additional Phone Number Type of Phone — Select — Cell Home Work Emergency Contact Information Emergency Contact Name * First Last Emergency Contact's Phone Number * Emergency Contact's Email Address * Emergency Contact's Relationship with Adolescent * Medical Information Medical Information for the Individual Diagnosed with Cancer Name of the Individual Diagnosed with Cancer * First Last Treatment Status * Active Treatment Survivor Thriver (select all that apply) Type of Cancer * Stage of Cancer * — Select — I II III IV Diagnosis Date * Name of Oncologist * If you don't know this, please write: "N/A". Adolescent's Relationship to Individual Diagnosed with Cancer * If the Adolescent is the individual diagnosed with cancer, please write: "N/A". Additional Information How did you hear about Wellness House of Annapolis? * If an individual or organization referred you, please write their name here: If you have any other children, family members, or other loved ones who may benefit from our programs and services; please write their name(s), age(s), and relation to you here: Questionnaire (to be completed by Adolescent) Please have the Adolescent complete this questionnaire. 1. What kind of social media do you use? * 2. What have you been told about the cancer diagnosis? * 3. What are your thoughts about the cancer diagnosis? * 4. Since the diagnosis, are you still involved in the same activities? How has your life changed? * 5. Have you seen a counselor either private or in school? * 6. Do you have any allergies or take any medications? Please list them out here. * 7. What are your strengths? * 8. What are your goals for the future? * 9. What is your biggest need right now? * 10. What do you hope to gain from participating in our programs? * Program Waiver Agreement Please check each box to show that you acknowledge and understand the following statements. The programs at Wellness House of Annapolis which include but are not limited to Healing Touch, Massage, Reiki, Reflexology, Counseling, Support Groups, Mindfulness, Meditation, Educational and Nutrition Seminars, Exercise Programs, and Social Activities, are offered as complimentary services to those experiencing cancer either as a patient or a caregiver. I understand these services are not a substitute for medical treatment or the advice of my medical professional and that the teachers, practitioners, or participants do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. * I understand I understand that social and special interest programs such as Book Club, Healing Music, Support Groups, Meditation and Mindfulness Classes, Therapeutic Art, and Member Gatherings are offered as a source of stress relief, peer companionship, support and relaxation and are not to be used as a substitute for medical treatment. I understand the leaders/guests do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. * I understand I understand that Healing Touch and Reiki are simple, gentle, complimentary energy based approaches to health and healing that can assist my body in its natural ability to heal. I understand that the practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. * I understand I understand that I should seek approval from my physician prior to receiving massage at Wellness House of Annapolis to ensure that my current medical conditions do not interfere with receiving massage. * I understand I understand the exercise programs which include but are not limited to Tai-Chi, Pilates and Yoga are offered by trained and/or licensed professionals to be beneficial to my health and well-being. I understand the class leaders do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. As with all exercise programs, I understand that I should seek the approval of my physician before beginning the practice. * I understand I understand that nutrition and other educational seminars are offered periodically by Wellness House in areas of interest to our membership. Presenters are invited by Wellness House because of their special knowledge or expertise, but under no circumstances do they diagnose conditions, prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. * I understand I affirm that I alone am responsible to decide whether to participate, and to what degree to participate in the programs offered by Wellness House of Annapolis. I hereby agree to irrevocably release and waive any claims that I have now or may hereafter have against Wellness House of Annapolis and its staff, practitioners and volunteers. * I understand Limitations of confidentiality: If there is a threat to your life or others, this information cannot be kept confidential, and our counselors are mandated to report relevant information to the authorities. Limitations of our confidentiality include threats against yourself or another person, physical or sexual abuse or neglect. If you are experiencing a mental health emergency, support is always available, please call the Anne Arundel County Warm Line at 410-768-5522 or dial 9-1-1. * I understand Signature of Parent / Guardian Signature of Parent / Guardian * Date *
