Dr. Tunishai Ford
Discovering ... Your
Own Uniqueness!
Your Own Uniqueness, Inc.
presents
GENERAL MEDICAL INFORMATION
Participant's First, Last Name:
PARENT/ GUARDIAN AUTHORIZATION
Parent/ Guardian's First, Last Name:
Would it be okay to release this information  to us? Please answer, Yes or No
Please answer questions to the best of your ability and knowledge.
FOOD ALLERGIES:
Do you have any food allergies we should know about?  Please answer, Yes or No.
If yes, please list any food allergies
that we should know about.
PHYSICAL DISABILITIES OR MEDICAL CONDITIONS:
Do you have any physical disabilities or medical conditions? Please answer, Yes or No.
If yes, please list any physical
disabilities or medical conditions
we should be aware of.
Will these conditions or disabilities prevent you from completing this program? Please answer, Yes or No.

We will be serving you refreshments and lunch during the STEP UP program and will need to know what foods would be safe for your
consumption. Also, it is mandatory that we know what your physical and/ or medical limitations are, so that if possible, we can provide whatever
accommendations are available for you. Please fill out the questionnaire below to the best of your ability and knowledge, so we can best know
what foods can be brought in or prepared and if special access or seating is required.  If you should have any questions, please feel free to
contact us via email at you.inc@hotmail.com or phone at 734-285-2041.  Thank you in advance for your cooperation and welcome again to the
STEP UP program.
The  STEP UP Program
The  STEP UP Program