Recreotherapy
Registration for ACES Online Community
Section 1: Participant Information
Name of participant
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact
First Name
Last Name
Relationship to participant
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Does the participant have the ability to give informed consent for the purpose of this registration?
Yes
No
If yes, you can skip to the next page. If no, please put caregiver, parent or guardian's name, phone number, email, and relationship to the participant here:
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How did you hear about us? (choose 1)
Community organization
Family or friend
Online or social media
From Concordia
From Recreotherapy
Other
If you said other, please indicate how you heard about us here:
What are some of you past, current and future interests and hobbies?
Do you have any physical, cognitive or mental health conditions that we should be aware of?
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Section 2: Program goals
I am joining this program because I need to (check all that apply)
Be more physically activity
Build meaningful relationships
Keep my mind active
Feel less lonely and isolated
Reduce boredom
Have a greater sense of meaning and purpose
Express myself creatively
Enjoy life more
Feel a sense of acheivement
Feel a sense of belonging
Try new activities
Participate in something fun and enjoyable
Stay busy so my caregiver can get guilt-free respite
Learn something new
Other
If you said other, please share your reason for participating here:
What types of activities or experiences are you interested in participating in (check all that apply)
Physical activity (standing or seated aerobics, yoga, dance, stretching, tai chi, physical games etc. )
Cognitive stimulation (reminiscing, current events, brain teasers, trivia, cards, games, etc.)
Social connection (discussion groups, socializing, etc.)
Creative expression (music, art, drama, writing, dance, etc.)
Relaxation (mindfulness, meditation, journaling, gratitude, etc.)
Other
If you said other, please share the type of activities you would like to do here:
Would you be interested in (check all that apply)
1:1 activities with a recreation therapy student
Small group activities with other participants facilitated by a a recreation therapy student
Intergenerational activities with participants of different generations facilitated by a recreation therapy student
Mall walking group
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Section 3: Criteria
I am over 19 years of age or a legal parent/caregiver of a minor of someone who cannot give consent
Yes
No
I have access to a computer or tablet with a stable internet connection
Yes
No
I don't have access to a computer or tablet with a stable internet connection, however I am interested in participating in programs by phone.
Yes
No
Not Applicable - I have the required technology
I am willing to participate in this free pilot project with virtual or phone programming (1:1 and small groups)
Yes
No
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Section 4: Acknowledgements
I authorize Recreotherapy to photograph /video me and use such photograph(s)/video(s) in all forms of media, for education and promotional purposes
Yes for all proposes
Only for educational purposes
Only without my name
Never
I hereby agree to the waiver & release of liability https://drive.google.com/file/d/1Fr01agerqDfF-s_GEGAGLuhnpwfNCKpR/view?usp=sharing
Clear
I hereby agree to this client confidentiality agreement https://drive.google.com/file/d/1e6MZzyld9gHCee4_Xgik12umiff_yrI2/view?usp=sharing
Clear
By clicking submit you are agreeing to the waiver/release of liability and the confidentiality agreement, even in the absence of a signature
Submit
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