Club Beacons - Registration Form
Please complete and PRINT this form to bring to Club Beacons, a weekend social club for adults with disabilities (pilot of for individuals aged 16-29) held at Beacons, Inc., 6150 Yarrow Drive, Suite E, Carlsbad, CA 92011. Please note that the online "Waiver and Release of Liability" Form must also be completed (available at: https://www.beaconsnorthcounty.com/club-beacons).

Please note: ALL REQUIRED fields must be completed to activate the submit button. The button will not work if a required field has not been completed. Thank you!

1. HOURS: Each Club Beacons event is 3 hours ($30 per event or per each 3 hour club session).

2. PAYMENTS: Cash or checks. Please make checks payable to: Beacons, Inc. Payment may be provided on the day of the event but please submit registration and waiver forms at least one day before the scheduled activity.

3. DEADLINE(S): Please complete the Waiver and Registration forms and submit to Beacons, Inc. by the day before the scheduled Club Beacons event to ensure that there is sufficient staffing in place. For last minute additions to Club Beacons, please telephone or email us to make sure space is available and so that Beacons, Inc. can plan accordingly. Thank you!

4. CANCELLATIONS:
(a) Because staffing is determined based upon signs-ups, please cancel at least 24 hours before the scheduled event.
(b) Beacons, Inc. reserves the right to cancel any Club Beacons session if less than 10 participants are signed up by the Wednesday before the scheduled event that week. In the event a Club session is canceled, payments will be promptly refunded.

5. TO PRINT FORM: A copy of the completed/submitted form will be sent to the email address provided below and can be printed at that time.

6. Please bring the completed and SIGNED form with payment to: Beacons, Inc., 6150 Yarrow Drive, Suite E, Carlsbad, CA 92011.

7. QUESTIONS? Please contact Beacons, Inc. at:
Email: BeaconsNorthCounty@gmail.com
Telephone: 760-448-6230
Website: https://www.BeaconsNorthCounty.com

8. NONPROFIT STATUS: Beacons, Inc. is a California nonprofit 501(c)(3) public benefit corporation.

Please note that Club Beacons is designed to facilitate social activities with adults with mild/moderate disabilities using staffing ratios of approximately 5:1 or larger. Individuals who require smaller ratio support, and/or who have a history of elopement, disruptive or aggressive behaviors, self injurious behaviors, behaviors that are likely to injure others, or who have medical or other issues that require more intensive or 1:1 monitoring, supervision or assistance may not be dropped off without a personal care attendant, respite worker or other person responsible for their care.

Refunds will not be provided in the event a participant is asked to leave the activity, event or program because of maladaptive, unsafe or disruptive behaviors that interfere with the enjoyment of other attending.
Email address *
Participant’s Name: *
Your answer
Email of person completing form: *
Your answer
Person completing this form: *
Street Address: *
Your answer
City *
Your answer
State: *
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Zip: *
Your answer
Cell phone: *
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Home phone: *
Your answer
BEACONS' USE OF PHOTOS: I (as self or as Conservator) give Beacons permission to take photos of the participant to use in its discretion in promotional, marketing, outreach and other materials. *
MEDIA'S USE OF PHOTOS: Beacons, Inc. may share any photos taken of the participant with the media for use by the media. *
ALLERGIES: Does the participant have any allergies (eg. food, medication, other)? If yes, please list the allergies and known reactions. If none, type in "none." *
Your answer
DISABILITY(IES): What is the participant's disability(ies) or diagnosis(es)? *
Required
If "Other" was checked above or if you wish to provide more information, please provide information here. Thank you.
Your answer
SEIZURE SUPPORT - IMPORTANT: If the participant has seizures, please submit or bring the participant’s seizure protocol and describe BELOW 1) possible triggers (e.g. flashing lights, loud noises, etc.), 2) what to look for, 3) how long they typically last, 4) when to call parent, and 5) when to call 911. Thank you. (If participant does not have seizures, type “N/A”) *
Your answer
Special interests and/or abilities of the participant *
Your answer
SUPPORT NEEDED: Please describe support needed by staff or others while at Club Beacons (e.g. toileting support, communication support, other). If none, type or write "none". *
Your answer
Does the participant have a 1:1 in school settings? *
Does the participant have a BIP? *
BEHAVIORS: Please let us know if participant has a history of any behaviors that may warrant additional supervision or support (for example: disruptive behaviors if bored or irritated, difficulties keeping hands to oneself, tripping or hitting of others to get attention, biting, and the like). IF NONE, please type in "none." *
Your answer
BEHAVIORS: Please describe what, if any, positive interventions we can use when behaviors arise.
Your answer
BEHAVIORS: I understand that Club Beacons is designed to facilitate social activities for persons with mild/moderate disabilities using staffing ratios of 5:1 or larger, and that individuals who require smaller ratio support, and/or who have a history of elopement, disruptive behaviors, self injurious behaviors, behaviors that may injure self or others, or who have medical or other issues that require smaller ratios or 1:1 to monitor or assist the individual, MUST BE ACCOMPANIED by a personal care attendant, respite worker or caregiver responsible for the individual's care. *
MEDICAL: I understand that Beacons, Inc. will not administer any medical services or emergency care other than basic first aid. In case of injury or emergency, Beacons will call the person(s) listed as the emergency contact(s) and/or 911 at the expense of liability of the participant/conservator/legal guardian. *
Physician's name: *
Your answer
Physician's contact information: *
Your answer
Emergency Contact #1 (Please list name and telephone number) *
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Emergency Contact #2 (Please list name and telephone number) *
Your answer
AUTHORIZED SIGNATURE: Once this completed form is submitted, it will be sent to the email address provided at the top of this form. Please print this form, sign it and bring to Beacons, Inc. on the day of the event. Thank you!
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Date *
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