KAS Social Group Registration
Online tracking form for Adults with Autism who are attending KaleidAScope's Virtual AND/OR In Person Social Group
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What is your FIRST and LAST name? (REMEMBER TO USE THIS NAME WHEN YOU LOG INTO ZOOM SOCIAL GROUPS) *
What is your birthday? *
MM
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DD
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YYYY
Have you been diagnosed with Autism Spectrum Disorder (includes PDD-NOS, ASD, Asperger's, HFA)? *
What is your PHONE NUMBER (with the area code)? *
Do you text message with that phone number? *
Can KAS staff text message you about group at that phone number? *
What is your email address? (make sure you check your spelling) - THIS IS HOW WE WILL SEND YOU THE ZOOM LINK FOR VIRTUAL GROUPS
What is your FULL mailing address? (the place where you get mail). Include the STREET, CITY, STATE, and ZIP CODE
Please include the FIRST and LAST name of an emergency contact person. (this would be a person we could contact in the case of an emergency during group) *
Please list the PHONE NUMBER of your EMERGENCY CONTACT person (with area code). *
How did you hear about KAS social group? *
Do you give KAS permission to use your picture and/or video in marketing and public relation materials? *
How do you attend/will you attend social group?
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Is there anything else we should know about you?
By initialing below, you are acknowledging that you are an adult (18+/out of high school) with an ASD diagnosis. You are acknowledging that these groups are simply opportunities facilitated by KAS - but not fully staffed or chaperoned. 
(put your initials in for your answer if you agree with all of this)
*
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