KAS Social Group Registration
KaleidAScope, Inc. is excited to continue to offer our regular facilitated social events for adults with autism. 
These groups are intended for individuals who are 18+ years old and done with high school. 
While KAS does facilitate the group - we do not provide direct support for any participants unless it was been previously arranged through waiver or private pay contracts. Individuals who do receive direct support through another agency are able to participate -but we do request that the provider agency issue KAS with copies of the DSP's clearances. 
If you are choosing to come to an "in person" group for the first time - it helps us to know that you'll be there. Please contact Sara Kitchen to let her know when you think you'll come so that she can have staff know to be on the lookout! Sara's contact information is skitchen@kas-erie.org (email) or (814) 824-4515 (phone). You can also contact Sara with other questions regarding the social opportunities.

PLEASE NOTE: THIS IS NOT A CLINICAL GROUP. These social opportunities are to promote age-appropriate socialization amongst peers with ASD. Individuals who participate are able to come/go as they please.

IF YOU ARE A PROVIDER COMPLETING THIS FORM ON BEHALF OF A PARTICIPANT OR CLIENT - PLEASE USE THE CLIENT'S NAME FOR THE FIRST QUESTION.

Find more information about KAS and all of the things we've got going on by checking out our website and facebook page:

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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? *
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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 AND THE CALENDARS/UPDATES
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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