If paying with Respite, please reach out to your DSHS Case Manager and ask them to add Willow Place to your Provider list.

If an individual (parent, guardian, payee) is paying for the Participant, provide their information below

Willow Place is a Day 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.

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.

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 $10) 3. We offer an afternoon session from 1:00pm-4:00pm. Participants picked up after 4:05 PM will incur a late fee of $5, billed at the end of the month. Bus riders are exempt from late fees. 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.

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. We are not responsible for dietary restrictions.

Willow Place operates as a snack‑free program to maintain a safe environment for all participants, including those who may be food‑aggressive. No snacks are provided during morning or afternoon sessions. A designated lunch break is held from 12:00pm–1:00pm. Participants who attend both sessions are required to bring an appropriate lunch each day. If a participant stays for the full day and does not bring a lunch, a snack may be provided as needed. Willow Place does not offer refrigeration or microwave access for packed lunches. Food is only available during the lunch hour or during pre‑planned program activities, which will be listed on the program calendar in advance.

Birthday treats at Willow Place will be held exclusively during lunch hour, from 12:00 PM to 1:00 PM. The Willow Place manager requires at least two weeks' advance notice for any birthday celebrations at Willow Place. If you plan to bring treats like cake or cupcakes, please ensure they are store-bought, as homemade items are not permitted.

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 Quilceda Community Services (QCS) permission to use my name and any photo or video images of me to demonstrate the programs and/or services in which I participate. These images may be used for purposes including, but not limited to, public relations, education, fundraising, and marketing. This may include publication or display in newsletters, newspaper articles, and on the QCS website or social media platforms.I release QCS, its employees, successors, and appointees from any and all claims related to the use of these images. I grant this permission voluntarily and waive any right to monetary compensation. This agreement remains valid for the entire duration of my participation, or the participation of the individual on whose behalf I am signing, with QCS, beginning on the date it is signed. I understand that I may change or revoke this agreement at any time by providing written notice to QCS.

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 30 minutes, 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.

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.).

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.

If a participant is ill, Willow Place staff will call Emergency Contacts (listed in Section 2 of this form) to come pick up the participant. If requested, the participant must be picked up within 30 minutes. If the participant has not been picked up within 30 minutes, 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 their 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 30 minutes. If they are not picked up within one hour, Willow Place will charge $25 per hour for isolation care.

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 30 minutes. If the participant has not been picked up within 30 minutes, 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.

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.