Participant information Form

ILADD, Inc.
1393 West Oak Street
Zionsville, IN 46077
E: info@iladdinc.org
T: (317) 207-0805
Participant information Form

All Applicants must complete this information prior to being accepted as a Participant.
Full Name*

First NameLast Name
Date of Birth*
Gender
Race/Ethnicity
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Phone Number*
Optional: Cell Phone Number (in case we need to text you)
Please enter a valid phone number.
E-mail*

Confirmation Emailexample@example.com
Participant's Medical/Health Information
Primary Diagnosis/Disability
List Any Medical Conditions
Medications:
Seizures?*

YesNo
If yes, type of seizures and frequency:
List any allergies (food or medicine)
Currently Receiving Benefits*

YesNoHave applied, waitingOther
Has a driver's license?*

YesNo
Behavioral Issues?
Parent/Guardian/Staff Information (1):
Parent/Guardian/Staff Information (1)- Name:*

First NameLast Name
Relationship: (Mother, Father, Guardian, Staff, etc.)*
Email (type twice for accuracy confirmation)*

Confirmation Emailexample@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian/Staff Information (2):
Parent/Guardian/Staff Information (2)- Name:

First NameLast Name
Relationship: (Mother, Father, Guardian, Staff, etc.)
Email (type twice for accuracy confirmation)

Confirmation Emailexample@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about ILADD?*
Medical Insurance Company Information

*We have provided space for two different forms/companies information. If you do not have a second company you want to list, please skip to the next section.
Insurance Company Name*
Policy Number*
Insurance Company Phone Number*
Physician Name
Physician Phone Number*
Optional 2nd Insurance Company Name
Optional 2nd Policy Number
Insurance Company Phone Number
Emergency Contacts (Please provide 2)
EMERGENCY CONTACT #1 - Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number 1*
Please enter a valid phone number.
Phone Number 2
Please enter a valid phone number.
Emergency Contact #2
EMERGENCY CONTACT #2 Name*

First NameLast Name
Relationship:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number 1*
Please enter a valid phone number.
Phone Number 2
Please enter a valid phone number.

Participant Eligibility Requirements and Guidelines
ILADD, Inc. offers programs, clubs, organized outings, and classes (collectively, “activities”) to adults with intellectual and developmental disabilities. The following are our Participant Guidelines. We reserve the right to change these at any time.

·      Participants must be an adult (at least 18 years of age).

·      Participants must submit a Participant Information Form, read and agree to the Participant Code of Conduct, and read and agree to the Release and Waiver of Liability and Emergency Medical Care Authorization and Media Release.

·      Following submission of the necessary ILADD forms for participation, the self-advocate and/or caregiver will meet with the ILADD Program Manager to provide additional information with regard to necessary supports, medical or behavioral concerns and ways ILADD staff and volunteers can best meet the needs of the participant. Any information gathered will be confidential and for use only by ILADD staff and volunteers during ILADD programming.

·      If a Participant needs one-on-one support for physical, personal hygiene, medical, or behavior issues, the Participant will need to bring a caregiver with him/her to the activity. The caregiver will need to pay their own expenses while on the activity.

·      ILADD staff or volunteers cannot dispense medication. Reminders to take medication independently may be permitted.

·      Guidelines specific to ILADD organized group outings:
- Participants must register for all outings with the Program Manager.
- Participants may choose one outing per month.
- Participants may be placed on a Wait List for any small group outing that has limited attendance or seating.
- Please cancel no less than 24 hours before the small group outing if you are unable to attend (to enable someone on the Wait List to attend).
- If a Participant fails to cancel more than 24 hours in advance of a small group outing two times in four months, the Participant may be suspended from participating for at least one month.
- Prepayment will be required for ticketed events.
Participant's Name*

First NameLast Name
Participant's Signature (use your mouse to sign or finger on mobile)*

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Parent/Guardian Name (if applicable)

First NameLast Name
Parent/Guardian Signature (if applicable) (use your mouse to sign or finger on mobile)

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Participant Waiver & Release
For and in consideration of being permitted to participate in and/or watch any and all clubs, activities, programs or events (“Activity”) provided by ILADD, Inc. (“ILADD”), the sufficiency of such consideration is hereby acknowledged, Participant, as hereafter signified, and for his/her personal representatives, assigns, heirs, and next of kin, hereby freely, voluntarily, and without duress execute this Release and Waiver under the following terms:

RELEASE AND WAIVER: Participant does hereby release, waive and discharge ILADD and its affiliated companies, volunteers, agents, employees, officers, directors, successors, and assigns (collectively referred to herein as “ILADD and Affiliates”) from any and all liability, loss, claims, costs, attorneys’ fees, expenses, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from Participant’s participation in the Activity with ILADD and Affiliates whether foreseen or unforeseen, known or unknown. Participant understands that this Release and Waiver discharges ILADD and Affiliates from any liability or claim that the Participant may have against ILADD and Affiliates with respect to any bodily injury, personal injury, illness, death, or property damage that may result from the Activity with ILADD and Affiliates. Participant also understands that ILADD and Affiliates do not assume any responsibility for or obligation to provide financial or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness.

ASSUMPTION OF RISK: Participant understands that ILADD and Affiliates do not own, operate, or control the locations of the Activities and that unstable or unexpected conditions at the Activity may require changes in the planned Activity or might cause inconvenience or harm to Participant. Participant understands and agrees that ILADD and Affiliates do not assume responsibility or liability for, and have not made, and do not make any representations whatsoever regarding Participant’s personal health and safety, or that of Participant’s property while participating in this Activity.

Participant understands that there may be inherent risks to his/her health or well-being as a result of Participant’s participation in this Activity which ILADD and Affiliates can neither anticipate nor eliminate including, but not limited to, unfamiliarity with the Activity location; travel to, from and around the Activity location; unfamiliarity with laws, culture, or customs; environmental or other conditions of the location of the Activity; inadequate or unavailable healthcare facilities or assistance; inadequate, faulty, or inappropriate training or instruction of personnel or equipment; accident or mistake. Participant fully accepts and assumes such risks and all responsibility for losses, costs, and damages Participant incurs as a result of participation in the Activity.

EMERGENCY MEDICAL CARE AUTHORIZATION: The Participant certifies that he/she is physically and emotionally capable of full participation in the Activity, however, the Participant recognizes that occasionally an individual participating in an Activity may face a health emergency requiring local hospitalization or emergency treatment. Participant authorizes ILADD and Affiliates, to secure emergency medical care, hospitalization, or other treatment for Participant. However, Participant understands ILADD and Affiliates are under no duty to secure such care or assist Participant in any other way in such a health emergency. Participant does hereby release and forever discharge ILADD and Affiliates from any claim whatsoever which arises or may hereafter arise on account of any first aid, medical care, hospitalization, treatment, or service rendered in connection with the Activity.

MEDIA RELEASE: Participant does hereby grant and convey to ILADD all rights, title, and interests in any photographic images and video or audio recordings of Participant (collectively referred to herein as “Media”) made by ILADD and Affiliates during any Activity and grants ILADD permission to use such Media in any and all of its publications, including website entries, without payment or any other consideration. Participant understands and agrees that such Media will become the property of ILADD. Participant now authorizes ILADD and Affiliates to edit, alter, copy, exhibit, publish, or distribute such Media for purposes of publicizing ILADD Activities or for any other lawful purpose.

INSURANCE: Participant understands that, except as otherwise agreed to by ILADD in writing, ILADD does not carry or maintain health, medical, or disability insurance coverage for any Participant. Each Participant is expected to obtain his/her own medical, health, and/or disability insurance coverage.

OTHER: Participant promises to abide by all rules and requirements of participation in any Activity provided by ILADD. Participant understands that by breaking any rule or requirement, or for any other reason deemed appropriate by ILADD and Affiliates, his/her participation in any Activity may be immediately terminated. Participant agrees that this Release and Waiver is intended to be as broad and inclusive as permitted by the laws of the State of Indiana. Participant agrees that should any portion of this Release and Waiver be held invalid, the remaining portion shall remain in effect.
I, Participant, being of legal age and capacity, have read, understood, and agree to the terms of this Release, Waiver, and Authorization
Participant Name*

First NameLast Name
Participant Signature (use your mouse or finger to sign)*

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Date*

MonthDayYear
Date
Parent/Guardian Name (if applicable)

First NameLast Name
Parent/Guardian Signature (if applicable) (use your mouse or finger to sign)

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ILADD Participant Code of Conduct
ILADD, Inc. offers programs and activities to Participants with intellectual and developmental disabilities and has developed this Code of Conduct to assure that they will be provided in a welcoming, respectful, and safe environment.

·      I will treat all ILADD staff, volunteers, and participants with respect, courtesy, and kindness. I will make sure that everyone is included and that no one is left out or left behind.

·      I will behave in a way that is safe and does not put myself or others at risk of physical harm.

·      I will follow all rules and policies adopted by ILADD and any of the venues we visit as guests. I will follow directions given by ILADD staff and volunteers and representatives of the venues we visit as guests.

·      I will not use abusive or harmful language about or to another person. I will not harass, threaten, embarrass, or insult other persons.

·      I will not make inappropriate or unwanted physical, verbal, or sexual advances on other persons.

·      I will not smoke in non-smoking areas. I will not drink or use illegal drugs at ILADD events.

I understand that if I violate this Code of Conduct I will be subject to a range of consequences that could include limitation or condition of my participation in ILADD programs and activities and/or prohibition from participation in ILADD programs and activities.
Participant Name*

First NameLast Name
Participant Signature (use your mouse or finger (on mobile) to sign*

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Parent/Guardian Name (if applicable)

First NameLast Name
Parent/Guardian Signature (if applicable) (Use mouse or finger (on mobile) to sign)

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Should be Empty:

Participant information Form

Participant's Medical/Health Information

Parent/Guardian/Staff Information (1):

Parent/Guardian/Staff Information (2):

Medical Insurance Company Information

Emergency Contacts (Please provide 2)

Emergency Contact #2

Participant Eligibility Requirements and Guidelines

Participant Waiver & Release

ILADD Participant Code of Conduct