Cascadia Clubhouse Member Registration Form

Cascadia Clubhouse Member Registration Form

Cascadia Clubhouse provides recreational activities for our members (adults 18+ with developmental disabilities) in Skagit County.
You do not need to refill this form each time your son/daughter attends. We are a "drop-in" program. The only time it will need to be resubmitted is when there are important changes.

Once you click on the "Submit" button, we will receive the application and you do not need to complete it again. Thank you!
Member* Information

*There are no membership fees or dues, only fees for the sessions or events the member attends.
Member Name

First NameLast Name
Member Birthdate

MonthDayYear
Date
Member's Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member's living arrangement:

With familyWith non-familial guardianin an adult family homeLiving independentlyOther
Who has permission to pick the member up from Cascadia Clubhouse?
Please indicate whether or not we have permission to use photos of the member taken during activities or events for our newsletters, social media, website, and other marketing materials.

YesNo

Emergency Contacts

Cascadia Clubhouse protects your privacy with our Information Privacy Policy found here:
Primary Caregiver / Emergency Contact #1

This should be someone who lives with the participant
Caregiver's Name

First NameLast Name
Relationship to Member
Caregiver's Primary Phone Number
Please enter a valid phone number. We use this for urgent communications.
Caregiver's Alternate Phone Number
Please enter a valid phone number.
Caregiver's Email
example@example.com
WE COMMUNICATE CHANGES AND IMPORTANT INFORMATION IN OUR NEWSLETTER. It takes quite a bit of staff time preparing the information but it is important to read. Would you like to add this email to our newsletter mailing list?

YesNo
Emergency Contact #2
Emergency Contact Name

First NameLast Name
Relationship to Member
Phone Number
Please enter a valid phone number.
Emergency Contact #3
Emergency Contact Name

First NameLast Name
Relationship to Member
Phone Number
Please enter a valid phone number.

Billing Information

Please fill out this page to the best of your ability, contact us at info@cascadiaclubhouse.org or 360-928-5884 if you have questions. Lack of necessary information here will result in the rejection of this registration form until adequate billing information is provided.
Payment for this member's attendance will be paid by:

Respite (DDA)Parent or GuardianOther
Respite Payment Info

If paying with Respite, please reach out to your DSHS Case Manager and ask them to add Cascadia Clubhouse to your Provider list. If you do not know if you are signed up or able to receive "respite", please contact the Skagit DDA Field Office @ (360)429-3103
IF PAYING WITH RESPITE, please enter the DDA caseworker's name

First NameLast Name
Member's Client ID# (in ProviderOne)
Respite Caseworker's Email
example@example.com
Respite Caseworker's Phone Number
Please enter a valid phone number.
Private Pay Information

If an individual (parent, guardian, payee) is paying for the member, provide their information below
Billing Name (if paying WITHOUT RESPITE)

First NameLast Name
Relationship to Member
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Email
example@example.com
Billing Phone Number
Please enter a valid phone number.
How would you like to receive your monthly invoices?

EmailMail

Policies
About Cascadia Clubhouse

Cascadia Clubhouse is an activities program for adults with developmental disabilities. Our mission is to build an equitable community for adults with developmental disabilities by fostering social connections and personal growth through the arts, recreational activities, and enrichment programming. Because Cascadia Clubhouse is an activities center only, we do not provide medical care. If a member requires assistance with eating, using the restroom, or taking medication, then a caregiver must attend with the member. Staff will not administer medication and will only assist in the restrooms in case of emergency.
Initial here to indicate that you have read and understood the above:
Member Requirements

1. Cascadia Clubhouse reserves the right to remove a member if they pose a safety threat to staff members or other members. 2. All members must be at least 18 years of age and be able to feed themselves and care for themselves while in the restroom. Cascadia Clubhouse DOES NOT provide individual assistance with feeding or in the restroom with the exception of emergencies. Repeated need for assistance will require the member to bring a parent/guardian/caregiver with them while attending Cascadia Clubhouse. 3. All members must annually update registration and emergency contact information when requested. 4. Members must abide by Cascadia Clubhouse rules and follow the directions of staff.
Initial here to indicate that you have read and understood the above:
Attendance Policy

Members will only be charged for sessions attended. If a member is present for at least 60 minutes of a session, they will be charged for the entire session. We offer a morning session from 9am-noon. Drop-off for morning sessions is between 8:30am and 9am and pick-up for morning sessions is between noon and 12:30pm. We offer an afternoon session from 12:30-3:30pm. Drop-off for afternoon sessions is between noon and 12:30pm, and pick-up for afternoon sessions is between 3:30pm-4pm. Attendance will be taken for each session. A member will not be released to someone who is not their parent/guardian, or is not listed above ("Who has permission to pick up the member?" in Section 1 of this form), unless it is Skagit Transit Paratransit and the participant's name is on the official roster. If there is a change in attendance, it is up to the care provider to contact Paratransit to cancel the participant's ride.
Initial here to indicate that you have read and understood the above:
Food Allergies

Cascadia Clubhouse staff will do their best to prevent members with allergies from ingesting foods they are allergic to. However, members often share snacks from home and therefore Cascadia Clubhouse may not be able to prevent such ingestion at all times. If a member has a severe allergy, it is best that a caregiver attend with them. PLEASE SEND APPROPRIATE SNACKS/LUNCH SO THEY HAVE FOOD WHEN OTHERS ARE EATING.
Initial here to indicate that you have read and understood the above:
Snacks and Lunches

Healthy snacks are handed out by staff at 10am and 2pm daily at no extra charge, and a break is provided for lunch from 12:00-12:30. If a member intends to stay at Cascadia Clubhouse for the entire day (both sessions), they will be required to bring an appropriate lunch each day. If a member is staying for the full day and does not bring a lunch, a lunch may be provided and charged $5 to the participant's account. We don't provide refrigeration for packed lunches and snacks, but a microwave is available.
Initial here to indicate that you have read and understood the above:
Suspension

If a member is sent to Cascadia Clubhouse when they have been suspended, have been notified that they may not attend due to causing disruption to our activities, or have an unpaid bill older than 30 days, the caregiver will be called to pick the member up and they must be picked up within ONE hour. After one hour, if the member has not been picked up, Cascadia Clubhouse will charge $75 per hour until they are picked up. A report may be made to DSHS depending on the situation.
Initial here to indicate that you have read and understood the above:
Lost Items

Expensive items should not be brought to Cascadia Clubhouse as staff will not be held responsible for their loss. Unidentified items that are found will be held in our "Lost and Found" for up to 30 days. We recommend writing the member's name on items most like to be left behind (water bottles, lunchboxes, coats, etc.).
Initial here to indicate that you have read and understood the above:
Emergency and Safety

Once per quarter, a mock fire drill will be performed so all members are familiar with the procedure and exit strategies. In the event of an emergency, staff will blow a whistle signaling to other staff and volunteers to evacuate their members from the building. Staff will bring all members to designated safe areas outside the building while the problem is resolved. Staff will call the caregivers of each member present for pick up once it is safe to do so.
Initial here to indicate that you have read and understood the above:
Member Illness

If a member is ill, Cascadia Clubhouse staff will call the Emergency Contacts (listed in Section 2 of this form) to come pick up the member. If requested, the member must be picked up within ONE HOUR. If the member has not been picked up within one hour, Cascadia Clubhouse will charge a fee of $75 per hour for isolation care. In the event of a serious illness or injury, if the Emergency Contacts cannot be reached intime, the member may be transported to the nearest hospital for immediate care and treatment. Please report contagious conditions to the Cascadia Clubhouse office staff when they occur. We reserve the right to require a note from a healthcare provider prior to the member's return. A member should stay home at the first sign of a communicable disease. By doing so, you are protecting the Cascadia Clubhouse community from exposure to the illness. Signs a member should stay home: FEVER: A member should remain at home if they have a fever higher than 100.4 degrees Fahrenheit. The member may return to Cascadia Clubhouse after they have maintained a normal temperature (between 97 and 100.3 degrees F) for at least 24 hours without the use of fever-reducing medicine (such as Tylenol or Motrin). VOMITING: If a member has vomited in the last 24 hours, they should not be sent to Cascadia Clubhouse. DIARRHEA: If a member has had three or more watery stools in a 24-hour period, they should be kept home and return only after being symptom-free for 24 hours. COLDS: It is important for a member to stay home at the beginning of a cold, as it is the most infectious time and when she/he feels the worst. Please keep the member at home if they are experiencing discomfort that would interfere with their ability to participate activities (e.g. coughing, severe lack of energy). If the member experiences green or yellow nasal discharge that continues throughout the day, a cough that lasts longer than 10 days, or is accompanied by a fever or chills and is productive of discolored sputum, please consult with your physician. The member should only return to Cascadia Clubhouse when they no longer have symptoms and feel well. COUGH OR CONGESTION: The member should remain home if the cough or congestion interferes with breathing and/or if wheezing. CONJUNCTIVITIS (PINK EYE):Following a diagnosis of bacterial conjunctivitis, the member may only return to Cascadia Clubhouse 24 hours after antibiotic treatment has begun. Members with viral infection may return when eyes are clear. COXSACKIEVIRUS (HAND, FOOT, AND MOUTH DISEASE): A member must stay home during the acute stage of illness during fever or while lesions are present. HEAD LICE: A member may return to Cascadia Clubhouse only after treatment and when hair is free of nits. The member's head will be checked by staff. The member will be sent home if they arrive at Cascadia Clubhouse before the required 24-hour healing period. The member must be picked up within ONE HOUR. If they are not picked up within one hour, Cascadia Clubhouse will charge $75 per hour for isolation care.
Initial here to indicate that you have read and understood the above:
Disruptive Behavior

Some of our members may have issues with behaviors that disrupt activities and scare other members. Staff will do their best to remove the disruptive member to a calm area and help them with de-escalation techniques and calming exercises. Intentionally disruptive behavior will be addressed by staff adhering to Cascadia Clubhouse's Discipline Policy. Corporal punishment is never used. Rather, quiet time will be given if a member becomes increasingly irritated, loud, or nonresponsive to staff direction. Caregivers may be called if there is an ongoing issue, and the member may be removed from Cascadia Clubhouse if necessary and/or may receive suspension if behavior continues. If the member's caregiver is called, the member must be picked up within ONE HOUR. If the member has not been picked up within one hour, Cascadia Clubhouse will charge a fee of $75 per hour. We reserve the right to refuse service to members that cause disruption to our activities or pose a safety risk to themselves, other members, or staff.
Initial here to indicate that you have read and understood the above:
Sign and Submit

All of the information held within this document covers all activities both on-site and off-site of Cascadia Clubhouse. Please sign your name below to indicate that you have read, agreed to, and understood all the information in the Member Registration Form. The information in this packet is very important to Cascadia Clubhouse and to the members that attend. Please share this information with the caregiver if the member does not live with you.
Initial here to indicate that you have read and understood the above:
Date

MonthDayYear
Date
Welcome to Cascadia Clubhouse!

We are so excited to get to know our new member and welcome them in to our community!

Should be Empty:

Cascadia Clubhouse Member Registration Form

Member* Information

Emergency Contacts

Primary Caregiver / Emergency Contact #1

Emergency Contact #2

Emergency Contact #3

Billing Information

Respite Payment Info

Private Pay Information

Member Health and Behavior Information

Policies

About Cascadia Clubhouse

Member Requirements

Attendance Policy

Food Allergies

Snacks and Lunches

Suspension

Lost Items

Emergency and Safety

Member Illness

Disruptive Behavior

Sign and Submit

Welcome to Cascadia Clubhouse!