Student Information Form

Student Information Form

Social Saturday Groups
General Information
Parent Name

First NameMiddle NameLast Name
Parent Email
example@example.com
Parent Phone Number
Please enter a valid phone number.
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Ethnicity
Gender
Grade

Residence Information
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information
Primary Emergency | Contact Name

First NameLast Name
Primary Emergency | Phone Number
Please enter a valid phone number.
Primary Emergency | What is your relationship with this person?
Secondary Emergency | Contact Name

First NameLast Name
Secondary Emergency | Phone Number
Please enter a valid phone number.
Secondary Emergency | What is your relationship with this person?

Medical Information
Physician Name

First NameLast Name
Physician Primary Phone Number
Please enter a valid phone number.
Physician Secondary Phone Number
Please enter a valid phone number.
Preferred Emergency Hospital Name
Please list any of the followings: current medications, medication allergies, food allergies, or chronic health concerns.
Please list any additional information that may be helpful: (verbal/not verbal, sensory overload, etc..)
Has your child ever attended social skills group?

Yes, with another organizationYes, with Autism R.E.CNo

Enrollment History
School Name
City
State
Notes
Waiver:

I, hereby acknowledge that my child, will be participating in the Autism REC Programs, including but not limited to the Social Skills Group and any related activities. I understand that these programs involve physical, social, and emotional activities that may have inherent risks.

I acknowledge that my child has autism and may require additional support, accommodations, and supervision to participate in these programs. I understand that it is my responsibility to inform the program staff of any special needs or concerns related to my child's participation.

I hereby waive, release, and discharge Autism REC Programs, its directors, officers, employees, agents, and volunteers, from any and all liability, claims, demands, actions, and causes of action arising out of or in any way connected with my child's participation in these programs, including any injury, illness, or harm that may result from participation in the programs, except for any liability that may arise from the gross negligence or intentional misconduct of Autism REC Programs or its employees.

I acknowledge that I have read and understood this waiver and that I am voluntarily giving up my right to sue Autism REC Programs for any injuries, damages, or losses that may occur as a result of my child's participation in these programs.

Policy:

Autism REC Programs is committed to providing a safe, inclusive, and supportive environment for all participants, including those with autism. We strive to create programs that are tailored to the unique needs and interests of each participant, while also promoting social skills, communication, and independence.

We understand that participants with autism may require additional support, accommodations, and supervision to participate in our programs. We work closely with families to understand each participant's needs and to provide the necessary support and accommodations.

We have a team of trained and qualified staff who are experienced in working with individuals with autism. Our staff is trained in the following areas:

Autism awareness and understanding
Positive behavior support strategies
Communication and social skills development
Safety and emergency procedures
We also have policies and procedures in place to ensure the safety and well-being of all participants, including:

Staff-to-participant ratios that meet or exceed state requirements
Background checks for all staff and volunteers
First aid and CPR trained staff on site
Emergency procedures and evacuation plans
A zero-tolerance policy for bullying, harassment, or any other form of harmful behavior
We are committed to continuous improvement and welcome feedback from participants and families. We regularly evaluate our programs to ensure that we are meeting the needs and expectations of our participants and providing a high-quality experience for all.
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Student Information Form

General Information

Residence Information

Emergency Contact Information

Medical Information

Enrollment History