Member Profile
Please complete the following information profile.  
Once submitted and reviewed, you will be contacted by a member of the ASRC Team.
Please note that a Member Profile must be completed prior to attending any social/recreation groups.
Please email directly with any questions.
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Email *
Name of Person Completing this Profile *
I am completing this Profile... *
Name of Social-Recreation Member *
Date of Birth *
Address *
Phone number *
Additional Email Contact *
May we text you information/updates? *
Emergency Contact #1 (Name & Phone Number) *
Emergency Contact #1 (Email Address) *
Emergency Contact #2 (Name & Phone Number) *
Emergency Contact #2 (Email Address)
Does participant have ALLERGIES? *
If you answered YES to ALLERGIES, please list below: *
Education INFO: (participant currently enrolled in) *
If in school - Name of School
If working - Name of Employer
What Services are you/particpant currently receiving? *
Please list some of your /participant's STRENGTHS/ACCOMPLISHMENTS *
What are your/participant's FAVORITE ACTIVITES/INTERESTS?(Home and/or school) *
Do you/participant have any areas of AVOIDANCE/AVERSION we should know about? *
Please list any CHALLENGES/BEHAVIORS we should be aware of. *
HELPFUL HINTS/FUN FACTS: (Please list any coping strategies, second language, forms of communication, favorite food, significant life change) *
What would you/the participant like to gain from attending groups: (make friends, become more involved in the ASD community, increase independence, self-help, etc.) *
Please check whether you would like your contact information shared with families of ASRC.  This facilitates our efforts to help connect individuals and families outside of our social groups. *
PHOTO RELEASE - Please check below to authorize Autism Services & Resources CT (ASRC) to take and publish photographs/videos of you and/or my child for print, online, and/or video based marketing and company publications. (Please note public events such as our Autism Walk, Resource Fair, etc. are considered public events and ASRC has no control of who will or will not be photographed.) *
INDEMNIFICATION AND HOLD HARMLESS - Please check below to authorize that you understand the risks involved in participating in any of Autism Services & Resources CT (ASRC) Recreational/Social Activities.  You acknowledge that the activity and facilities they take place at may pose significant risk of injury to you/your child(ren).  You are aware that you/your child(ren) are responsible for your/their own safety.  You hereby grant for yourself/your child(ren), heirs, executors, or administrators, waive and release any and all claims for damage ever had or now have against Autisms Services & Resources CT, its successors and assigns, employees, agents, and representatives for any and all kinds of activities.  You understand that Autism services & Resources CT is not responsible for medical, hospital, emergency room or transportation expenses for any incidental illness or injury or you/your child(ren).  You also expressly agree that ASRC has the total discretion to determine if you/your child(ren) meet the criteria or otherwise qualify or to permit you/your child(ren) to participate in any group or program.  Finally, Autism Services & Resources CT has the total discretion to determine that you/your child(ren) should be removed from any group or program and ASRC's determination concerning such participation or removal shall be final and cannot be appealed. *
Digital Signature of Member Below (First and Last Name) *
Today's Date: *
Digital Signature below of Parent if Member is under 18 (First & Last name or TYPE "N/A") *
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