Line Dancing Registration Form

Line dancing classes will be held in a safe parking lot with no traffic during class time.

All participants must maintain social distancing whenever possible.

All participants must wear masks correctly throughout the activities.

Please do not bring food to class.

There will be an indoor bathroom available for use by participants. If use of bathrooms leads to the need for janitorial services, an extra cleaning fee will be charged to the participant.

Participant Name *

First Name Last Name

Gender *

Male Female Non-binary

Date of Birth *

Date

Level of Independence (choose one):

Minor Guardianship Independent Other (Please contact Mosaic)

Phone Number *

Please enter a valid phone number.

Phone Number

Enter a second contact number if you have one.

Participant's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Living status (choose one): *

Live alone with paid care providers Live alone with family providing care Live alone, no care providers Live in group home with paid care providers Live in shared housing with one roomate Live in shared housing with more than one roomate Live with family Other (Please contact Mosaic)

Is the participant's mailing address the same as the home address? *

Yes No

Participant's Mailing Address (Complete if different from Home Address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email

Confirmation Email Confirm email address

In order to insure that as many participants as possible have access to in-person programs, we may limit attendance to only one session per person. Thus, please choose below your first and second choices for sessions.

Please pick which class is your first choice for attending:

Saturday, April 10 Saturday, May 8 Saturday, June 10

Please pick which class is your second choice for attending:

Saturday, April 10 Saturday, May 8 Saturday, June 10

What transportation will participant use to get to the Line Dancing class? (choose one) *

Drive self Dropped off by family or care provider Dropped off by Clallam Connect bus City's fixed bus routes Other (Must contact Mosaic in advance)

Will a Family Member or Care Provider stay with the participant during class? *

Yes No

Name of Emergency Contact *

First Name Last Name

Phone Number of Emergency Contact *

Please enter a valid phone number.

Email of Emergency Contact

example@example.com

Name of Second Emergency Contact *

First Name Last Name

Phone Number of Second Emergency Contact *

Please enter a valid phone number.

Email of Second Emergency Contact

example@example.com

Wheelchair Dependent? *

Yes No

Special Communication Needs? *

Yes No

Please explain any special communication needs:

Sensory Issues? (check all that apply) *

Yes, sensitive to loud noises Yes, sensitive to flickering/strobe lights Yes, sensitive to bright lights Yes, sensitive to smells Yes, sensitive to touch Yes, sensitive to "scratchy" or other textures against skin Other sensory issue (Please contact Mosaic) No sensory issues

List all relevant allergies

List all relevant health issues

Physician Name

First Name Last Name

Physician Phone Number

Please enter a valid phone number.

To finish registering, please make sure that you have also completed the In-Person Code of Conduct, the Covid-19 Liability Release Waiver and the Covid-19 Questionnaire.