Triangle D&A University Spring 2024 Class Registration

Triangle D&A University Spring Class Registration

Class descriptions can be found at www.arctriangle.org/services-programs/classes
Participant Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Gender Identity*

FemaleMaleNon-BinaryOtherChoose not to answer
Race/Ethnicity (choose all that apply)*

Asian/Pacific IslanderBlackLatinXNative/Alaskan Native AmericanWhiteOtherChoose not to answer
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CareGiver/Parent/Guardian Information
Name (if applicable)

First NameLast Name
Email (if different from participant)
example@example.com
Phone Number (if different from participant)
Please enter a valid phone number.
Address (if different from participant)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cooking & Nutritition Class Registrants Only

List any Food AllergiesList any Dietary Restrictions
My Classes

Classes Offered*

Chair ExerciseMorrisville- Thursdays, 12:00pm, beg 4/4 (8 weeks)

$25.00 Quantity

Cooking & NutritionDurham- Tuesdays, 2:30pm, beg 4/2 (8 weeks)

$105.00 Quantity

Sing-a-longONLINE - Tuesdays, 10:00amm, beg. 4/9 (8 weeks)

$25.00 Quantity

Gentle Yoga ONLINE- Wednesdays, 7:00pm, beg 4/3 (8 weeks)

$25.00

Total

$0.00

Credit Card

Media Consent I hereby authorize The Arc of the Triangle, Inc. (DBA Triangle Disability & Autism Services) to photograph/video the Participant. The photographs/videos may be used for the following purposes (please check all that apply):

Publicity for Triangle Disability & Autism Services (ex. Training, news articles, press releases, Newsletter/E-Newsletter)

Internet: Triangle Disability & Autism Services Website or Social Media (Names will NOT be used on social media or our website)
Choose all that apply:*

Media Consent for Publicity for Triangle Disability & Autism ServicesMedia Consent for Internet- TDAS Website or Social MediaI do not give consent
Informed Consent and Acknowledgement I agree to participate in the community programs of The Arc of the Triangle, Inc. (DBA Triangle Disability & Autism Services). I understand that taking part in this event is completely my choice. I understand that there is no anticipated risk or discomfort from participation in the program. I also understand that I may decline/refuse to participate in any part of the program and may withdraw my consent to participation at any time. I understand the venues where these events may be held cannot be held liable for any accident/emergency occurring during a Triangle Disability & Autism Services community program. I understand Triangle Disability & Autism Services community programs do not provide one-on-one supports/supervision.

Medical Release and Authorization In the event of a medical emergency involving the Participant, I give my permission to The Arc of the Triangle, Inc. (DBA Triangle Disability & Autism Services) to attempt to reach the emergency contact(s). If the situation necessitates, the staff members have my permission to provide first aid/CPR and/or seek emergency medical treatment for the Participant. I further agree to be responsible to all costs attached to this treatment. I release Triangle Disability & Autism Services and its staff members from any further liability.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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Triangle D&A University Spring Class Registration

Participant Information

CareGiver/Parent/Guardian Information

My Classes

Credit Card