ASRC @ Clifford Beers - Recreation Program MEMBER PROFILE
Please complete the following information profile.  
Please note that a Member Profile must be completed prior to attending & receiving information for any social/recreation groups.
Please email: ASRCinfo@cliffordbeers.org with any questions.
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Email *
Please Select Group Interested in: *
Please Select Your Participation Level: *
Required
Groups you would like to attend: *
Required
Name of Person Completing this Profile *
I am completing this Profile for...  *
Relationship to the Individual *
If other, please identify below
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Name of Person Requesting to Join (or continuing to attend) the Recreation Programs *
Date of Birth *
Best Contact Email Address *
Best Contact Phone Number *
May we text you information/updates?  *
Required
Home Address *
Emergency Contact #1 (Name & Phone Number) *
Does participant(Do You) have ALLERGIES? *
Required
If you answered YES to ALLERGIES, please list below:
Education/Employment Info: (participant currently enrolled in) *
Required
If working - Name of Employer/Company
What Services are you/participant 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 @ Clifford Beers.  This facilitates our efforts to help connect individuals and families outside of our social groups. *
PHOTO RELEASE - Please check below to authorize ASRC @ Clifford Beers 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 ASRC @ Clifford Beers 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  ASRC @ Clifford Beers, its successors and assigns, employees, agents, and representatives for any and all kinds of activities.  You understand that  ASRC @ Clifford Beers 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 @ Clifford Beers 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,  ASRC @ Clifford Beers has the total discretion to determine that you/your child(ren) should be removed from any group or program and  ASRC @ Clifford Beers determination concerning such participation or removal shall be final and cannot be appealed.
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READ AND CLICK YES to AGREE: 

ASRC @ Clifford Beers - RecConnect Zoom Etiquette
Just as expected at an in-person events, participants must communicate respectfully. This is important for ALL virtual events too. Here are some reminders:

-My contributions to any chat features will be visible to all who are participating in that program. 
-The use of profanity, slurs, and/or any verbal aggression directed toward others (even as a joke) or asking inappropriate questions of others will result in comments being deleted and/or being muted by the mentor/host.
-Staff reserve the right to delete comments as well as remove participants from the session (or groups all together) should they continue to use profanity, slurs, and/or exhibit verbal aggression toward others, ask inappropriate questions of others or don't adhere to the requests of the mentor/members, to stop. 
-ASRC @ Clifford Beers staff will be present for each virtual event, moderating each session and helping to facilitate the chat. 
-Each participant has their own experiences, opinions, emotions, and knowledge, it is okay to mute or turn off camera if I need a moment or some space, however:
-I will be present for each session and find a space away from distractions and conversations while attending group to stay focused.
-I will mute myself if I am speaking to someone in my home/room/space, etc.
-I will turn off and leave my camera if I need to walk around or use the restroom.
-If I want to speak but the conversation is moving too fast and I'm having trouble jumping in, I can use the 'raise hand' reaction and someone can invite me to speak.
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Required
Digital Signature of Member (First and Last Name)
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Digital Signature below of Parent if Member is under 18 (First & Last name or TYPE "N/A")
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Today's Date:
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