FullPower Spring Class Registration

Triangle D&A University Full Power Workshop Registration

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

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Participant Email
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Caregiver/Parent/Guardian Name
Name

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Email
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Address

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Emergency Information
Name & Relationship*

Emergency Contact Full NameRelationship to Participant
Phone Number*

My Classes*

DURHAM IN-PERSON FullPower Self-Empowerment/Personal Safety Workshop (minimum of 5 people) First THURSDAY of each month. 6:00-7:00pm Triangle Disability & Autism Services, Durham. Begins: • May 4 • June 1 • July 6

$25.00 Quantity

Total

$0.00

Credit Card

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.
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)
Media Consent- Publicity for Triangle Disability & Austism Services*
Select Yes or No
Media Consent- Internet- Website or Social Media*
Select Yes or No
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 Full Power Workshop Registration

Credit Card