The Special Friends Network Questionnaire and Member Information Form

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Hello Friends. Please take the time to fill out this form. Help me make The SFN all that we want it all to be!

Participant Name (first and last) *

Name of Parent or Guardian if applicable

Mailing/street address with postal code

email address *

Emergency Contact phone number (while Participants are at events) *

Participant Age and Birthdate

Please tell us more about you (the participant). Include any Special Needs or Medical conditions you fell we should know about. Including, any seizure disorders etc. *

If You (the participant) becomes anxious, upset or has any sensory issues, How can we best comfort or redirect you/them?

Do you have any allergies or dietary restrictions? (If Yes, please inform us at each event and always send an epi-pen) *

What kind of events do you most enjoy? Include any activities you would like to see planned for future SFN events. (ie. Dances, bowling, book clubs etc) *

What kind of activities/events do you NOT like or would not choose to attend?

Is cost a factor in your participation in any event? *

Please share any questions, concerns, suggestions, ideas you may have. What would you like to see available? Not just through The SFN but in the community, society, school etc. What needs does your family have that are not being met? What would make your life easier, or the lives of your loved ones? *

Additional comments or information you would like to share:

Do you give permission for The Special Friends Network to use photographs taken at events for use on our Facebook page and/or Website etc? *

Yes

I acknowledge that by submitting this form, I agree to be added to the email list and am free to unsubscribe at anytime. *

yes

Required

I/we understand that participants in The SFN events and activities, are in a group setting and have access to some guidance from Volunteers HOWEVER all participants are expected to be independent enough to participate without the need for one on one assistance/support. If an individual does need personal support for personal hygiene/care, SAFETY or to fully engage in an event without causing harm or distress to themselves or other attendees, the participant MUST attend with a personal support worker or family member. *

Agree

Do you agree to the Following for any and all future SFN events? We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him (her) to participate fully in Events and activities planned and held by The Special Friends Network, and hereby release and forever discharge The Special Friends Network and any of its associates or volunteers from any and all responsibilities and liability claims. *

Yes

Required

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