Arc for the River Valley Member Application
We will utilize this information for grants. No personal information will be shared. Membership is $30 a year.
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First Name *
Last Name
Date of Birth *
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Address *
City *
State *
Zip *
County *
Phone Number *
Emergency Contact Name *
Emergency Contact Number *
Emergency Contact Relations to Member *
Liability Release Form                                                              The Arc for the River Valley, its staff, volunteers, and any and all persons connected to the organization are hereby released and discharged from any and all liability, claims, and causes of action of any type whatsoever arising out of or in any way connected with participation in all Arc-sponsored activities and events. In the event of situations involving minors or dependents in which medical treatment is required, every reasonable effort will be made to contact the persons listed on the membership form. If the Arc is unsuccessful in contacting the persons listed, consent and permission are given for the treatment by competent medical personnel as determined by those supervising the event. Further, consent and permission are given to hospitalize and secure proper treatment for above-named member. By typing my first and last name and date, I agree to the above. *
Confidentiality and Conduct Agreement
The Arc for the River Valley provides advocacy, education, and recreation for those with intellectual and developmental disabilities. I hereby pledge to respect and not disclose or discuss with others any sensitive or confidential information associated with Arc members or their caregivers that may come to my attention. To ensure the safety and well-being of everyone who participates in activities and events of the Arc for the River Valley, I agree to abide by the rules of conduct set forth by the Arc staff or volunteers who supervise any and all such activities and events. I understand that violations can result in verbal warnings, dismissal, or banning from future Arc activities and events, at the discretion of those supervising said activities or events. By typing my first and last name and date, I agree to the above.
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Photo Release Form
I hereby authorize the Arc for the River Valley to take photos or videos of me in the course of any and all activities and events sponsored or associated with the Arc for the River Valley. I acknowledge that these photographs or videos can be used in informational or promotional materials including but not limited to brochures, flyers, newsletters, reports, audio-visual presentations, the Arc's Facebook page, and web sites of the Arc for the River Valley and its partnership pt beneficiary organizations. In addition, I understand that these photographs or videos can be shared with external media organizations, including but not limited to newspapers, radio stations, and television stations, in order to further promote the Arc for the River Valley. By typing my first and last name and date, I agree to the above.
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What is your current mailing address you would like your newsletter to be delivered to?
Is member: *
Is member associated with a group home, service provider or agency? *
If member is associated with a group home or agency, which one?
Does member require any mobility aids? *
Does member require any communication aids? *
Are there any medications or medical concerns with member that Arc staff/ volunteers should be aware of? *
What is the member's age group? *
How would you identify yourself? *
Are you of Hispanic/Latino/Spanish origin? *
What is your gender? *
Is the member a female head of household?
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What is the member's annual income?
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With permission, is it okay to post photos of member on Facebook? *
Is it okay to use photos of member in our Newsletters? *
How would member like to receive future Newsletters? *
If you would like to receive newsletters via email, what is your current email?
Will your service provider be billed for your membership?  *
What address do we need to send your renewal notices to? Please include street address, city, state, and zipcode.
How would you like to pay the $30 annual membership fee? *
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