Special Recreation Services Group Registration Form

Private Pay Group Activity Program Registration Form (New Registrants, Please Do Not Fill out until after you speak with Debbie)

Please fill out ONLINE (Please DO NOT print out and then mail in. This is an ONLINE FORM ONLY.) If you are NEW to the group then there will be a one time $20 registration fee which will be added to your first invoice. PLEASE FILL IN EVERY LINE. IF NOT APPLICABLE, WRITE IN “N/A”
Individual's Name*

First NameLast Name
Individual's Date of Birth*

MonthDayYear
Individual's Contact Number:*
E-mail*
example@example.com
Individual's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of your Supports Coordinator (if you do not have an SC, please put N/A. Debbie Smith is not an SC and you should not be putting her name here)*

First NameLast Name
Email or phone # of your Supports Coordinator.*
AUTHORIZED EMERGENCY CONTACTS: (someone that is available during activity hours). If you live in a group home, please list your manager first.
Emergency Contact #1:*

First NameLast Name
Relationship*
Contact Number*
Emergency Contact #2:*

First NameLast Name
Relationship*
Contact Number*
MEDICAL INFORMATION: (*In case of emergency, the following information will be shared with emergency personnel.) This information MUST be filled in if you will be attending activities without any staff/family/guardian present during the entire activity. This form is HIPAA protected.
Primary Doctor's Name*

First NameLast Name
Primary Doctor's Phone Number*
Please enter a valid phone number.
Please list any psychiatric/behavioral issues or phobias?*
Do you have any health issues that we should know about in case of an emergency so that we may notify the appropriate medical personnel?(diabetes, seizure disorders, heart problems, asthma, etc.)*
What medications are you currently taking and dosage?(Please include vitamins and dietary supplements) You can attach a med list at the end of this form if you prefer.*
Please list any allergies (food, drugs, environmental, etc).*
Local Hospital of Choice*

Lehigh ValleySt. Luke's
Health Insurance Name*
Health Insurance ID # *
Type of Disability?*

IntellectualAutismMental HealthOther
Level of Intellectual Disability*

MildModerateSevereNot applicable
How many hours can you be unsupervised in the community?*
Reading ability?*

NoneSomeFull
Can you tell time?*

YesNoa little
Are you able to handle money?*

YesNowith some help
Highest Grade level completed in school?*
CONSENT TO PHOTOGRAPH/VIDEO: I hereby grant permission to be photographed/recorded while participating in activities with Special Recreation Services and am aware that such photographs or videos may be used for the purpose of publicity to promote programming for persons with Disabilities. (write not applicable in the box if you don't grant permission)
Signature*

Clear
Date*

MonthDayYear
Date
I consent to have my address/phone#/email handed out to other program participants so they can send me holiday, birthday and other types of cards and/or contact me for socialization. (write not applicable in the box if you don't grant permission)
yesNo
Signature*

Clear
Date*

MonthDayYear
Date
CONSENT TO OBTAIN/RELEASE INFORMATION: I hereby authorize Special Recreation Services to obtain from or release to MH/DS, my private therapist or doctor, my Supports Coordinator and/or my provider agency, information pertaining to my participation in this program such as psychiatric and medical history, social history and mental status. This consent is effective from the date this form is signed and expires in 1 year. I have been told that in order to protect confidentiality of my records, my agreement to obtain or release information is necessary and that this permission is limited for the purpose and to the person or organization listed on this form.
Please list names of your provider agency, case worker, supports coordinators, therapists and/or doctor that you give permission for us to communicate with.*
Signature*

Clear
Date*

MonthDayYear
Date
I have read or been read the Special Recreation Services Policies and Procedures (located at www.specialrecreationservices.org) and I agree to abide by them to the best of my ability.
Signature*

Clear
Date*

MonthDayYear
Date
Person completing this Referral Form if other than participant:
Name*

First NameLast Name
Your relationship to the participant*
The information in this box is optional to answer but will be helpful for us when we apply for grants and funding. You may choose more than one.

African AmericanAlaska NativeAmerican IndianAsianNative HawaiianOther Pacific IslanderIndianMiddle EasternWhiteOther
The information in this box is optional to answer but will be helpful for us when we apply for grants and funding. You may choose more than one.

Hispanic/LatinoNot Hispanic/Latino
The information in this box is optional to answer but will be helpful for us when we apply for grants and funding. You may choose more than one.

FemaleMaleOther
Release and Hold Harmless Agreement: I, the undersigned have read and understand, and freely and voluntarily enter into this Release and Hold Harmless Agreement with Special Recreation Services, Inc. understanding that this Release and Hold Harmless Agreement is a waiver of any and all liabilities. I understand the potential dangers that I could incur while participating in certain activities including but not limited to: swimming, running, jumping, cooking, crafts, bowling, amusement rides, exercising, horseback riding, dancing or riding in a vehicle. Understanding those risks, I hereby release Special Recreation Services, Inc. its officers, directors, employees, volunteers and anyone else directly or indirectly connected with the company from any liability whatsoever in the event of injury or damage of any nature (or perhaps even death) to me or anyone else caused by or incidental to my electing to participate in the activities provided by Special Recreation Services, Inc. I understand that it is in my best interest to obtain and keep current, medical health insurance and/or accident insurance. I understand and recognize and warrant that this Release and Hold Harmless Agreement, is being voluntarily and intentionally signed and that my information may be released to an insurance company.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
If you will be attending the activities independently (without staff or a family member) and you have an ISP, please attach the most current one.

Cancelof
Should be Empty:

Private Pay Group Activity Program Registration Form (New Registrants, Please Do Not Fill out until after you speak with Debbie)

MEDICAL INFORMATION: (*In case of emergency, the following information will be shared with emergency personnel.) This information MUST be filled in if you will be attending activities without any staff/family/guardian present during the entire activity. This form is HIPAA protected.

I consent to have my address/phone#/email handed out to other program participants so they can send me holiday, birthday and other types of cards and/or contact me for socialization. (write not applicable in the box if you don't grant permission)

I have read or been read the Special Recreation Services Policies and Procedures (located at www.specialrecreationservices.org) and I agree to abide by them to the best of my ability.

Person completing this Referral Form if other than participant: