Willow Place Participant Registration Form
Willow Place provides recreational activities for our participants (adults 18+ with developmental disabilities) in Snohomish County.
Participant* Information*
There are no membership fees or dues, only fees for the sessions or events the participant attends.
Name
First Name
Last Name
Participant Birthdate
-
Month
-
Day
Year
Date
Participant Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant Living Arrangement:
Adult Family Home
Living Independently
With non-Family guardian
With Family
Other
Household Size:
Household Income:
Who has permission to pick the participant up from Willow Place?
Back
Next
Emergency Contacts
Primary Caregiver / Emergency Contact
This should be someone who lives with the participant.
Caregivers Name
First Name
Last Name
Relationship to participant
Caregiver's Primary phone number
Please enter a valid phone number.
Caregiver's Alternate phone number
Please enter a valid phone number.
Caregiver's Email
example@example.com
Would you like to add this email to our newsletter mailing list?
Yes
No
Emergency Contact #2
Emergency Contact Name
First Name
Last Name
Relationship to participant
Phone Number
Please enter a valid phone number.
Emergency Contact #3
Emergency Contact Name
First Name
Last Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Back
Next
Billing Information
Please fill out this page to the best of your ability, contact us at jayde.stewart@quilcedacs.org or 360-653-2324 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 Guardian
Other
Respite Payment Info
If paying with Respite, please reach out to your DSHS Case Manager and ask them to add Willow Place to your Provider list.
IF PAYING WITH RESPITE, please enter the DDA caseworker's name.
First Name
Last Name
Participant'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 Participant, provide their information below
Billing Name (if paying WITHOUT RESPITE)
First Name
Last Name
Relationship to Participant
Billing Address
Street Address
Street Address Line 2
City
State / 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?
Email
Mail
Back
Next
Participant Health and Behavior Information
While none of the staff at Willow Place are medical providers, we strive to protect our members' health as best as we can. Please provide detailed responses in this section in case it's needed for emergency responders. We are not responsible for dietary restrictions- we will do our best to accommodate, when possible, but please send appropriate snacks if medically necessary.
Primary Disability
Medical Conditions or Disabilities (e.g. seizures/epilepsy, Down Syndrome, diabetes, asthma, heart conditions, etc.)
Mobility Needs
Manual Wheelchair
Electric Wheelchair
Walker
Cane
Balance Issues
Fall Risk
None of the above
Allergies or Serious Reactions
Yes
No
If yes, please explain allergies or serious reactions
Communication Accommodations (ASL, hearing aids, etc.)
Participant behaviors of which staff should be aware:
What interventions or strategies do you recommend to help the participant when upset, stressed, or triggered?
Is the participant an elopment risk?
Yes
No
Maybe
If yes, please explain:
Additional information about the participant that would help improve the quality of their experience at Willow Place:
Will a caregiver be attending with the Participant? (We do not charge for caregivers)
Yes
No
Unsure
Back
Next
Policies
About Willow Place
Willow Place is an activities program for adults with disabilities. Our mission is to provide ability appropriate specialized recreation for individuals with Intellectual and Developmental disabilities of Snohomish County, provide respite for family, caregivers, and serve as a community volunteer site. Because Willow Place is 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:
Waiver and Liability Release
In consideration of the opportunity offered to participate in Willow Place Recreational Center, of Quilceda Community Services, I understand that even well-supervised recreation activities entail the risk of unforeseen accident, illness, or injury. Therefore, I hereby hold harmless, release, and waive all claims against Quilceda Community Services, its Board of Directors, employees, agents, or volunteers, and any other person(s) involved in the above-named activity/activities for all injuries, losses or damages suffered by me or my daughter/son or participant as a result of our participation in the above-named activity/activities. I accept full responsibility for the cost of treatment for any injury or damage suffered.
Initial here to indicate that you have read and understood the above:
Member Requirements
1. Willow Place reserves the right to remove a participant if they pose a safety threat to staff members or other members. 2. All participants must be at least 18 years of age and be able to feed themselves and care for themselves while in the restroom. Willow Place DOES NOT provide individual assistance with feeding or in the restroom with the exception of emergencies. Repeated need for assistance will require the participant to bring a parent/guardian/caregiver with them while attending Willow Place. 3. All participants must be able to transition from room to room or activity to activity independently. Willow Place does not provide one on one care at this time. 4.All participants must annually update registration and emergency contact information when requested. 5. Participants must abide by Willow Place rules and follow the directions of staff.
Initial here to indicate that you have read and understood the above:
Attendance Policy
Participants will only be charged for sessions attended. If a participant is present for at least 60 minutes of a session, they will be charged for the entire session. 2. We offer a morning session from 9am-noon. (Lunch Session 12:00-1:00pm for additional $5) 3. We offer an afternoon session from 1:00pm-4:00pm. 4. Attendance will be taken for each session. 5. 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 DART/ Paratransit/TAP(Homage) and the participant's name is on the official roster. 6. If there is a change in attendance, it is up to the care provider to contact DART/Paratransit/TAP(Homage) to cancel the participant's ride.
Initial here to indicate that you have read and understood the above:
Food Allergies
Willow Place staff will do their best to prevent participants with allergies from ingesting foods they are allergic to. However, Participants bring a packed lunch from home and therefore Willow Place may not be able to prevent such ingestion at all times. Willow Place staff encourage all participants to kindly not share food with each other. If a participant has a severe allergy, it is best that a caregiver attends with them.
Initial here to indicate that you have read and understood the above:
Snacks and Lunches
Willow Place is a snack free program which means we do not provide any snacks during Am or PM sessions. A break is provided for lunch from 12:00pm-1:00pm. 1. If a member intends to stay at Willow Place 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, Snacks may be provided to the participant. 2. We don't provide refrigeration for packed lunches and snacks, and a microwave is not available.
Initial here to indicate that you have read and understood the above:
Hand Sanitizer/Sunscreen
The warm rays of the sun can be harsh, especially on delicate skin. If you need a special sunscreen, or do not wish staff to assist in applying sunscreen, please make sure the participant knows how to apply it effectively themselves. Please provide adequate sunscreen with participants name written on it. If you do not want sunscreen applied, you must sign below: I am aware that, should the participant receive a sunburn, of any degree due to not: applying sunscreen, or having staff help apply sunscreen, or having the participant wear protective clothing to Willow Place as required by Willow Place, that the organization cannot be held responsible for the participants injury.
I give permission to Willow Place staff to assist in applying hand sanitizer/sunscreen if necessary.
Yes, may apply Sunscreen
No, may not apply Sunsceen
Yes, may apply Hand Sanitizer
No, may not apply Hand Sanitizer
Initial here to indicate that you have read and understood the above:
Photo/Video
Quilceda Community Services has my permission to use my name and photo or video image to help demonstrate the program and/or services of which I am a part of. Use of images may include but is not limited to public relations, educational purposes, fundraising, and/or marketing provided it is legitimately published or exhibited with discretion, newsletters, newspapers articles, QCS website/Facebook,ect. I release QCS, its employees, successors, and appointees from any and all claims that I may have. I hereby grant this release of my own free will and waive any claim of monetary payment. This agreement is valid for one year from the signed date.
I give permission to QCS/Willow Place to use my image and/or video for what is explained above.
Yes, I agree
No, I don't agree
Signature here to indicate that you have read and understood the above:
Date
-
Month
-
Day
Year
Date
Suspension
If a participant is sent to Willow Place 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 participant up and they must be picked up within ONE hour. After one hour, if the participant has not been picked up, Willow Place will charge $25 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 Willow Place 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
1. Once per quarter, a mock fire drill will be performed so all participants are familiar with the procedure and exit strategies. 2. In the event of an emergency, staff will blow a whistle signaling to other staff and volunteers to evacuate their members from the building. 3. Staff will bring all participants to designated safe areas outside the building while the problem is resolved. 4. Staff will call the caregivers of each participant 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 participant is ill, Willow Place staff will call the Emergency Contacts (listed in Section 2 of this form) to come pick up the participant. If requested, the participant must be picked up within ONE HOUR. If the participant has not been picked up within one hour, Willow Place will charge a fee of $25 per hour for isolation care. In the event of a serious illness or injury, if the Emergency Contacts cannot be reached in time, the participant may be transported to the nearest hospital for immediate care and treatment. Please report contagious conditions to the Willow Place office staff when they occur. We reserve the right to require a note from a healthcare provider prior to the participant's return. A participant should stay home at the first sign of a communicable disease. By doing so, you are protecting the Willow Place community from exposure to the illness. Signs a member should stay home: 1. FEVER: A participant should remain at home if they have a fever higher than 100.4 degrees Fahrenheit. The participant may return to Willow Place 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). 2. VOMITING: If a participant has vomited in the last 24 hours, they should not be sent to Willow Place. 3. DIARRHEA: If a participant 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. 4. COLDS: It is important for a participant 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 participant at home if they are experiencing discomfort that would interfere with their ability to participate in activities (e.g. coughing, severe lack of energy). If the participant 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 participant should only return to Willow Place when they no longer have symptoms and feel well. 5. COUGH OR CONGESTION: The participant should remain home if the cough or congestion interferes with breathing and/or if wheezing. 6. CONJUNCTIVITIS (PINK EYE):Following a diagnosis of bacterial conjunctivitis, the participant may only return to Willow Place 24 hours after antibiotic treatment has begun. participants with viral infection may return when eyes are clear. 7. COXSACKIEVIRUS (HAND, FOOT, AND MOUTH DISEASE): A participant must stay home during the acute stage of illness during fever or while lesions are present. The participant will be sent home if they arrive at Willow Place before the required 24-hour healing period. The participant must be picked up within ONE HOUR. If they are not picked up within one hour, Willow Place will charge $25 per hour for isolation care.
Initial here to indicate that you have read and understood the above:
Disruptive Behavior
Some of our participants may have issues with behaviors that disrupt activities and scare other participants. Staff will do their best to remove the disruptive participant to a calm area and help them with de-escalation techniques and calming exercises. Intentionally disruptive behavior will be addressed by staff adhering to Willow Place's Discipline Policy. Quiet time will be given if a participant becomes increasingly irritated, loud, or nonresponsive to staff direction. Caregivers may be called if there is an ongoing issue, and the participant may be removed from Willow Place if necessary and/or may receive suspension if behavior continues. If the participant's caregiver is called, the participant must be picked up within ONE HOUR. If the participant has not been picked up within one hour, Willow Place will charge a fee of $25 per hour. We reserve the right to refuse service to participants that cause disruption to our activities or pose a safety risk to themselves, other participant's, 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 Willow Place. Please sign your name below to indicate that you have read, agreed to, and understood all the information in the Participant Registration Form. The information in this packet is very important to Willow Place and to the participants that attend. Please share this information with the caregiver if the participant does not live with you.
Initial here to indicate that you have read and understood the above:
Signature
Date
-
Month
-
Day
Year
Date
Submit
Welcome to Willow Place
We are so excited to get to know our new participant and welcome them into our community!
Should be Empty: