2022 Participant Registration Form
This information, agreement and release of liability is required prior to participating in All the Difference, LLC programs.
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Email *
Today's Date *
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First Name *
First Name
Last Name *
Last Name
Primary Address *
Street, City, State & Zip of where you live the majority of the year
COUNTY of Primary Address *
What county is this located in?  For example, Penobscot County, Maine
Landline Phone Number for Primary Address
Area Code and Phone number of the LANDLINE for the primary address
Secondary Address
Street, City, State & Zip of where you reside part of the year
COUNTY of Secondary Address
What county is this located in?  For example, Penobscot County, Maine
Landline Phone Number for Secondary Address
Area Code and Phone number of the LANDLINE for the secondary address
Your Cell Phone *
Area Code and phone number of your cell phone.  Please have it with you during classes.
Do you have pets in your home?  If so, what type and please describe them?  (i.e., Hooper is a small black and tan dog and Fiona is a small dog with white with black and tan spots)
Which program(s) are you interested in? *
Required
#1 Emergency Contact Information: *
Provide name and phone number of the first person to contact in case of emergency.  What is their relationship to you?  Do they have a key to your home?
#2 Emergency Contact Information:
Provide name and phone number of the second person to contact in case of emergency.  What is their relationship to you?  Do they have a key to your home?
It appears that you have fallen.  We can see you on screen having difficulty getting up.  You are awake and possibly injured.  Keep in mind, we can't hear anything you are saying.  We are trying to call your cell and/or landline, but can't reach you (or anyone else there with you).  We would then call your emergency contact #1 and tell them what we are seeing.  If we can't reach your emergency contact #1, we will call contact #2 (if provided).  If we are unable to reach contact #2, what would you like for us to do?  Call 911 to dispatch emergency services to your location? *
You appear to be injured or have fallen.  We can see you on the floor, NOT moving. Keep in mind, we can't hear anything you are saying.  We are trying to call your cell and/or landline, but can't reach you (or anyone else there with you).  We would then call your emergency contact #1 and tell them what we are seeing.  If we can't reach your emergency contact #1, we will call contact #2 (if provided).  If we are unable to reach contact #2, what would you like for us to do?   *
You have suddenly disappeared from view.  We aren't sure if you just walked off screen or if you have fallen out of view.  We don't know what has happened.  We are trying to call your cell and/or landline, but can't reach you (or anyone else there with you).  We would then call your emergency contact #1 and tell them that we can't see you.  If we can't reach your emergency contact #1, we will call contact #2 (if provided).  If we are unable to reach contact #2, what would you like for us to do?  IT IS VERY IMPORTANT TO LET US KNOW IF YOU ARE LEAVING VIEW ON PURPOSE.  PLEASE USE THE CHAT BOX OR MAKE A SIGNAL INTO YOUR CAMERA AND MAKE SURE ONE OF US ACKNOWLEDGES YOUR INTENT. *
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