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EVENTS
CONTACT
ClubLife Participant Registration
First Name
Last Name
Email
Birthday
Phone
Gender
Choose an option
The participant will be attending
*
Required
Independently
With an aide or staff
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Parent/Guardian/Emergency Contact
Parent/Guardian/Emergency Contact
Phone
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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Today's Date
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Thanks for registering. See you soon!
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