Personal Experience Plan (PEP)

Contact Information

Name: Date Of Birth:
Age: Address:
State: Zip:
Phone: Sex: Male   Female

Pertinent Diagnoses: 
 

Name of legal representative (If not self)
Address:
 
State: Zip:
Phone: Relationship:
       
Family      
       
Mother: Phone:
Address: State:
Zip:    
       
Father: Phone:
Address: State:
Zip:    
       
Sibling: Phone:
Address: State:
Zip:    
 

Medical Information and Personal care

Allergies:   Yes  No    (If yes, Please describe allergies, treatment, and medication.)

 Please list any medical issues that might limit activity level or mobility.

Please List any adaptive equipment required (Wheelchair, Braces.)

 

Please List all of the medications, dosages and times given. If you prefer, please enclose a clear readable copy of their current medications chart with all known side effects. Also, please include instructions for topical lotions, eye drops or other specific needs.

Name of Medication Dosage/Amount AM Noon 4 PM HS
           


Please explain any special dietary needs or concerns
(Note any specific issues with certain foods, foods that may cause bowel issues, upset stomach, or foods that may not be desirable for the individual.)

Does this person have a seizure disorder?: Yes  No
(If YES, please answer the questions below).

What type of seizures?



Frequency of seizures?



Special treatments or instructions (Included symptoms and signs.)



 

 

Please list any other medical concerns, conditions or information that will help us to care for this individual.

For FEMALES only: Will the individual have specific menstruation: Yes  No
(If YES, Please describe care and how we can better assist the individual)

Check the following boxes if the individual can independently complete the task:

Get Dressed Eating Comb Hair Walking
Brush or Floss Drinking Use The Toilet Swimming
Bathing      
 
If you left any box unchecked, please describe in detail the care that the individual requires:



If not covered here, please list other assistance needed:

 

Communication Skills

Is this individual verbal (Able to speak as to be understood) YES NO (If YES, go to next section.)
Does this person know sign language YES NO (If NO, please fill in the remainder of this section.)

How does the individual communicate the following? (Please describe as much as you can)
 
I need something to eat?
I need something to drink?
I want to go or leave?
I need to stop or rest?  
I need assistance or help?
I need to use the bathroom?


Describe how the individual expresses emotions such as happiness, frustration, or sadness (please be specific).

 

Socialization

Please describe the individual's social skills and note any concerns such as community involvement, interacting with others, and or social limitations or difficulties:

 

Behaviors

Please check and describe all behaviors typically exhibited and note frequency
Use these frequency codes O = Often S = Seldom

Physical Aggression (Hitting, Biting, Kicking, Scratching)

Include cause and behavior                                                                                                 

Exhibited  

Verbal Aggression
(Screaming, Swearing at others, Threatening)

 Frequency

 

 

Please check as many of the following boxes that apply.
 
Takes others property Self injurious (harms self)
Property destruction High activity level (hyperactive)
leaves w/o notification (runs) Inappropriate sexual conduct
Eating non-edibles Other 
Other  

If you checked any of the above boxes, please give us detailed information including, but not limited to: description of behavior, tips and techniques to assist with behavior, and ways to help deescalate or help the person resolve the stressful situation:

 

 

Individual Interests (likes and Dislikes)


What type of activities does the individual enjoy: (Sports, Fishing, Bike riding, Video games, Dancing)


We strive to cater to each person and their individual goals. What does the participant most want to do while on their trip with Justus Venturing
(Dance, Canoe, Fish, Swim, Hike, Make friends)


What other specific information can you give us to ensure that this individual has the best experience.


Please List the persons

Likes:


Dislikes:

Note: Please include all areas such as activities, food, social, communication, animals, water and make specific references to extreme phobias. (fears)
 

Community Skills

Please check the areas where the individual is NOT independent

Identifies: Year, Month, Day, and Date
Tells time and minute
Uses the telephone
Identifies and understands currency (Money) and it's use
Makes purchases (Including acquiring change)
Understands and follows street safety signs and postings
 Utilizes public transportation (Bus, Taxi, Metro Mobility)
 Knows and communicates own address
 Can and will obtain assistance from appropriate workers (Ie. Police)

Additional comments or concerns

Please use the following space to indicate any other information that you feel is necessary in helping us to serve this individual and to ensure a successful and safe trip or event.


Cancellation Policy
This Policy is effective 1/1/2006

Justus Venturing will adhere to the following policy in regards to any cancellation of a trip or event.
NO cash refunds will be issued unless a trip or event is cancelled by Justus Venturing.

If payment has been received and you have to cancel, you will receive a full credit towards future trips or events if one of the following has occurred:

Medical issues or Hospitalization (Doctors note is required)
A family emergency

If for any other reason a trip must be cancelled, no credit or refund will be issued


By Checking this box You agree to our cancellation policy

Justus Venturing

Authorization to use photographs


Justus Venturing would like to have authorization to use photographs of:


Name of participant

For Promotional purposes ONLY. These photos my appear in written advertisements, displays, or on our website.
The photos will NOT be disseminated to any agency or person outside of Justus Venturing Org.

I grant Justus Venturing permission to use any photos and or video for promotional purposes.


Signature


Guardian (If not person named above)


Date


If you have any questions or concerns regarding this authorization, please feel free to contact us at (612) 396-4863. Justus Venturing can increase its consumer base by its advertisements. In allowing us to use this individual's photo we are able to extend our services to a greater audience.

Thank you for your consideration
 
Form completed by: Date Completed


Please print and sign your name below (if the individual is not their own guardian, the signature below must be a legal guardian or conservator)
I authorize Justus Venturing Organization
To view, utilize, and file all of the aforementioned information for the purpose of providing services to the participant named on Line 1 of this plan.

                              
Printed Name
Signature

 

   


Please make sure you have filled out and signed the Registration, and PEP then mail them to.

Justus Venturing Org
1895 Bush Ave
Saint Paul MN 55119
(612) 396-4863