CLUBLIFE | Register | Jackson, Michigan

ClubLife Participant Registration

First Name

Last Name

Birthday

Phone

The participant will be attending

Independently

With an aide or staff

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Parent/Guardian/Emergency Contact

Phone

Primary Diagnosis/Condition or Challenges

Suggestions for helping the participant perform successfully in a group setting

Strengths/Assests or Special Interests

Current Treatment Plan or Educational Program

Suggested Goal Area

What do you hope your participant will gain from clublife programs & events

I authorize CLUBLIFE to record and photograph my image and/or voice and/orthat of the subject named above for use by CLUBLIFE or its assignees in research, education and promotional programs. I understand and agree that these audio, video, film and/or print images may be edited, duplicated, distributed with or without charge, reproduced, broadcast, used online (website, social media, blog, etc) and/or reformatted in any form and manner without payment of fees, in perpetuity. I agree to the terms & conditions

I hereby authorize the release of information from clublife to student advocate agency (i.e. LifeWays, Hope Network, Alternative Choices etc). Please indicate if appropriate, case manage name and contact number. I agree to the terms & conditions

Case Manager

Caser Manager Phone

In case of an emergency, I, the guardian, request that CLUBLIFE secure appropriate medical treatment for the participant named above and then contact me immediately. I understand that any ambulance travel and medical treatment will be at my expense. If I refuse emergency medical treatment treatment for the participant named above, I will be asked to sign a waiver releasing CLUBLIFE and it’s employees of any liability in each incident. I agree to the terms & conditions

I have been given a copy of the CLUBLIFE participant handbook. I understand and agree to the policies and procedures set forth by CLUBLIFE. Should I, or the participant named above, not abide by these policies, I’m aware that there may be consequences, up to and including termination of participation of CLUBLIFE activities. I agree to the terms & conditions

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ClubLife Participant Registration

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