Friendship Matters - Registration Form

Friendship Matters - Registration Form

* Required

Participant Name* / Date of Birth*
Email* / Phone*
Address*

Support Needs:

Grade: / School:
Instructional Arrangement (ie: large group, small group, 1:1, behavior technician):
Please clearly indicate staffing needs for social, emotional or behavioral needs:*

PLEASE NOTE:If your child requires a personal assistant or aide, please attach his/her contact information. Staff will be required to pass a background check and must provide references.

Medical/Behavioral Notes* (Please include any aversions, sensitivities, and sensory needs):
Interests/Hobbies*
What does your child enjoy? How do they participate in the activity?
What types of peer personalities does he/she find reinforcing?
Parent/Guardian Name* / Phone*
Email*
Address*
Parent/Guardian Name* / Phone*
Email*
Address*
Emergency Contact* / Phone*
Email*
Address*

Child Health Information*

Name of Physician* / Physician Phone*
Please Describe Any Medical Concerns, Allergies, or Physical Conditions *

Person authorized to pick up your child*

Name (first, last): / Phone:

Authorization to Seek Medical Treatment*

In the case of accident or illness, I hereby give permission to WAAA to seek medical and/or surgical treatment that a medical professional may deem necessary for my child. In the event I or my emergency contact cannot be reached, I further authorize and consent to the administration of any and all medical, dental, and surgical examinations, operations, treatment, or all other related care, including the administration of drugs, tests, injuries, anesthesia, and/or blood transfusions to the above-named Minor that may be ordered by the physician and/or dentist in attendance at the medical center deemed necessary for emergency treatment. I hereby consent to the release of medical report(s) to any doctor or agency, and consent to the admission of the above named Minor to the hospital. I hereby assume full and complete responsibility for costs and expenses of such medical treatment, including the cost of emergency transportation to a medical facility.

______Printed Name of Parent/Legal Guardian and relationship to participant*

______Signature of Parent/Legal Guardian* Date*

Liability Release*

I authorize my child to participate in the Friendship Matters! Program (FMP). I acknowledge the inherent risks that may result from my child’s participation in this indoor and outdoor recreation program, including falls, fractures, or misbehavior of other children, all of which may result in injury to my child or damage to his/her/our property. I hereby assume these risks; release all claims held by me, my spouse, and my child arising from my child’s participation in the Friendship Matters! program; and accept full responsibility for the cost of all medical treatment to my child as a result of any injuries caused by or through such other risks.

I further agree to indemnify and hold harmless WAAA, their officers, employees, agents, students, and representatives from any injuries, liabilities, claims, damages, and expenses, including attorney fees, incurred by WAAA, me, my child, or on behalf of my child, arising from my child’s attendance and participation in the FMP, except that each party shall bear any liabilities or expenses arising in whole or in part from its own negligent acts or omissions or those of their respective officers, employees, agents, students, and representatives.

If the provision of this agreement is found to be invalid or unenforceable, then the remainder of this agreement will have full force and effect, and the invalidated provision will be modified, or partially enforced, to the maximum extent permitted by Washington State Law.

I have read all of the above terms and conditions, and I understand and agree to be bound by them.

______Printed Name of Parent/Legal Guardian and relationship to participant*

______Signature of Parent/Legal Guardian* Date*

Photo Release

Please note that approval of this release is not required for your child to attend FMP. However, your approval will help us to promote future workshops and other educational youth offerings.

I, as parent or legal guardian for “Minor,” give WAAA permission to use Minor’s materials (defined as visual images or audio recordings) in its internal publications for WAAA publicity, and in external publications such as local, regional, and national newspapers, magazines, websites, and brochures. There is no expiration date on this release, and I will not seek compensation for usage. This release does not include permission for WAAA to sell any of the materials.

______Printed Name of Parent/Legal Guardian and relationship to participant*

______Signature of Parent/Legal Guardian* Date*

How did you hear about us?*

WAAA Website_____ WAAA Email/Newsletter_____ WAAA Facebook _____ Other _____

Teacher/Counselor/Friend (name, we’d like to thank them) ______

Authorization for Background Check *

Applicable to all adult volunteers, aides, and participant family members on premises during WAAA programs. Please make additional copies if necessary.

To volunteer and participate with WAAA programs I understand that I must not have been convicted of any of the following:

(a) Convicted of any crime against children or other persons;

(b) Convicted of crimes relating to financial exploitation of a vulnerable adult;

(c) Convicted of crimes related to drugs;

(d) Found in any dependency action under RCW 13.34.040 to have assaulted or exploited any minor or to have physically abused any minor;

(e) Found by a court in a domestic relations proceeding under Title 26 RCW to have abused or exploited any minor or to have physically abused any minor;

(f) Found in any disciplinary board final decision to have abused or exploited any minor or developmentally disabled person

(g) Found by a court in a protection proceeding under chapter 74.34 RCW, to have abused or financially exploited a vulnerable adult.

I also recognize that WAAA will make a Request for Criminal Background History as ordained in the Child/Adult Abuse Information Act: RCW 43.43.830 through 43.43.845

Have you been convicted of any crimes listed in article (a) through (g)? *Yes______No______

______Printed Name of adult volunteer, aide, or participant family member(if accompanying child)*

______Signature* Date*

*Separate signatures needed for each adult accompanying participant