New Avenue Foundation Event Intake Form for the Wellness Walks Program Please complete this form for each person attending the event. Return to Jim Wurster jim@newfdn.org First and Last Name of Person Making Request: Phone Number: Email Address: First and Last Name of Person Attending: Mobile Phone in case of emergency: If a Caregiver is Attending - First and Last Name: Age of person attending (choose one): a. 55+ b. 19-54 c. 13-18 d. 0-12 Please indicate which ones apply to the person attending: Have a Cognitive Disability: Yes or No Have a Physical Disability: Yes or No Have a Psychiatric Disability: Yes or No Have a Non Visual Disability or Medical Condition: Yes or No Use a Walker: Yes or No Are Deaf or Hard of Hearing: Yes or No Are Blind or Visually Impaired: Yes or No Use a Service Animal: Yes or No Use a Ventilator/Respirator: Yes or No Use a Wheelchair: Yes or No Type of Wheelchair Used – Motorized / Manual Requires Interpersonal Attention from Staff: Yes or No Can Not Climb Stairs: Yes or No Can Only Walk Short Distances: Yes or No If the person attending has hearing or vision loss will he or she use: a. Braille: Yes or No b. Sensory Tour: Yes or No c. Audio Description: Yes or No d. ASL Interpretation: Yes or No e. Open Captioning: Yes or No Add Any Notes You May Have Here: