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Transition Services
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Post Adoption Services
Camp Bloomfield
Child Development Services (formerly Blind Babies Foundation program)
Child Development Services (formerly Early Intervention or Blind Babies Foundation)
Children and Family Services (formerly Lilliput Families)
Family Resource (NICU) Navigator
Foster Family Services
Kinship Support Services Program
Mental Health Services
Recreation for the Blind or Visually Impaired
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About Us
Our Mission, Purpose and Values
Fact Sheet and Additional Information
Our History
Board of Directors
Q&A with our President and CEO
Our Leadership
Locations
Equity Statement
Awards and Accreditations
Program Flyers
Ways to Help
Donate Now
Donor Advised Fund
Holiday Toy Drive and Wish List
Planned Giving
Major Gifts
Impact Council
Community Council
Corporate Sponsorships and Volunteer Opportunities
Workplace Giving
Giving Stock or Bonds
In-Kind Gifts
Volunteer Opportunities
Matching Gifts
Small Actions that Make Big Changes
Tribute Gifts
Monthly Giving
News and Events
Join The Conversation
Join us on Derby Day
Holiday Party
Annual Events
Coronavirus (COVID-19) Updates
Wayfinder Moments Newsletter
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Career Opportunities
Blog
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Program Areas
Children & Youth Services
Adult Services
Family Services
Find a Program
Adoption Services
Post Adoption Services
Camp Bloomfield
Child Development Services (formerly Early Intervention or Blind Babies Foundation)
Children and Family Services (formerly Lilliput Families)
The Cottage (TSC)
Family Resource (NICU) Navigator
Foster Family Services
Group Homes for Children
Kinship Support Services Program
Mental Health Services
Recreation for the Blind or Visually Impaired
Family Trainings & Workshops
Special Education School
Transition Services
Assistive Technology Training
Camp Bloomfield
Children and Family Services (formerly Lilliput Families)
Davidson Program for Independence (Residential for Visually Impaired)
Employment Services
Group Homes for Adults
The Hatlen Center (Residential for Visually Impaired)
Older Individuals who are Blind (OIB)
Orientation and Mobility Training
Recreation for the Blind or Visually Impaired
Transition Services
Adoption Services
Post Adoption Services
Camp Bloomfield
Child Development Services (formerly Blind Babies Foundation program)
Child Development Services (formerly Early Intervention or Blind Babies Foundation)
Children and Family Services (formerly Lilliput Families)
Family Resource (NICU) Navigator
Foster Family Services
Kinship Support Services Program
Mental Health Services
Recreation for the Blind or Visually Impaired
Health History and Special Needs
You will need the participant's Medi-Cal/insurance information and date of last TB skin test for this form.
Participant Information
Which activities are you planning to participate in:
Santa Barbara Half Marathon & 5K (Adults 18+ Only)
Participant's Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Age
(Required)
Choose Current Age
7
8
9
10
11
12
13
14
15
16
17
18+
PARENT/GUARDIAN Name
First
Last
PARENT/GUARDIAN Email
(Required)
Emergency Contact Phone
(Required)
Emergency Contact #2 Phone
(Required)
Physical and Independence Skills
PHYSICAL: Does the participant use any of the following?
(Required)
Walker
Crutches
Wheelchair
Has trouble walking/standing for long periods of time
None of the above
If you selected any of the above, please provide details:
INDEPENDENCE: Does the participant have any of the following conditions:
(Required)
Needs help using the toilet
History of bed-wetting
Needs help showering
Has sleep disorders or sleepwalks
None of the above
If you selected any of the above, please provide details:
DIETARY NEEDS:
(Required)
Needs help feeding himself or herself
Vegan or vegetarian
None of the above
If you selected any of the above, please provide details:
DISABILITIES OR MEDICAL CONDITIONS
Does participant have any of the following disabilities:
(Required)
Cerebral Palsy
Multiple Sclerosis
Muscular Dystrophy
Intellectual Disability
Down Syndrome
Autism
ADD/ADHD
Depression/Emotional Disorders
Behavioral Disorder
Seizures or Epilepsy
Other
None of the above
Seizures or Epilepsy
Date of Last Seizure
Typical seizure duration:
Frequency:
Potential triggers:
Other
If you chose "other" above, please provide details:
MEDICAL CONDITIONS
Does participant have any of the following medical conditions:
Diabetes
Psychiatric Treatment
Deaf or Hard of Hearing
Cancer
Stroke
Heart Disease
High Blood Pressure
Heart Attack
Irregular Heartbeat or Heart Murmur
Anemia
Sickle Cell Disease
Blood Clots
Thyroid Disease
Kidney Disease
Ear Infections
Sinus Infections
Bladder Infections
Mononucleosis
Chicken Pox
Mumps
Pneumonia
Skin Problems
Alcoholism
Drug Addiction
Asthma
Other
None of the above
Other:
Please describe other medical condition(s):
Asthma
Date of last attack:
Inhaler
Uses an emergency Inhaler
Does not use/need inhaler
Potential triggers:
Allergies
Please select any allergies below:
Bee stings
Insect Stings
Latex
Peanuts
Other foods
Dairy / Lactose Intolerance
Penicillin
Other medications
Other allergies
No allergies
Allergy Details
If you chose "insect sting" please describe this allergy in detail:
If you chose "other allergies," please describe these in detail:
Medication
Does participant take medication?
Yes
No
Medication Details
Add
Remove
Please list all medications and dosage details below. Use the + sign on the right to add more fields for each medication.
Tuberculosis, Insurance and Vaccination Information
Date of last tuberculosis skin test:
MM slash DD slash YYYY
Tuberculosis skin test results:
Negative
Positive
Insurance/Medi-Cal information
Max. file size: 50 MB.
Please upload a photo of your child's insurance/Medi-Cal card. If you are unable to upload, you can email this later.
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