IF Client Interest Form

Client Services Request

Please submit this form if you are interested in any of our services (ages 14+)
Attendee's Name

First NameLast Name
Parent/Guardian Name

First NameLast Name
Attendee's age
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
This is considered the Primary contact and #1 emergency contact
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name #2

First NameLast Name
Emergency Contact Phone Number #2
Please enter a valid phone number.
Emergency Contact Name #3

First NameLast Name
Emergency Contact Phone Number #3
Please enter a valid phone number.
How Soon would you like to start?

MonthDayYear
Date
What courses would interest you? Choose all that apply.

Personal Care and Self-Management (Launching soon)Social and Communication Skills (Launching soon)Safety and Emergency Preparedness (Launching soon)Community Integration and Employment Services (Launching soon)Love Beyond Labels Safe Dating (18+) (Launching in June)Move Your Body Dance Classes (Launching soon)Social Events (Launching May)Game Nights (Launching in June)Dungeons & Dragons Game Nights (Launching in June)
How Did You Hear About Us?
Any Additional information you would like us to know?
Are you open to volunteering? If so, do you have any specific skills or interests you'd like to contribute? Alternatively, offering general assistance is equally valuable if you prefer. (Background check required)
Please leave blank if you cannot Volunteer
Do you have any recommendation's on other programs or activities we should consider.
If you can upload a picture of the client please do for our files and the Customized lanyard.

Cancelof
By participating in our program, event, or activity, you agree to the use of your likeness, including photographs and videos, for promotional purposes on our social media channels, website, and other marketing materials. This may include but is not limited to posts, stories, advertisements, and promotional materials.

We may also tag or mention participants in posts related to the event or activity. If you do not wish to be tagged or mentioned, please inform the event organizers.

Your privacy is important to us, and we will never sell your information to third parties. However, please be aware that once images or videos are posted on social media platforms, they may be shared and viewed by others beyond our control.

If you have any concerns or objections regarding the use of your likeness, please contact us before participating in the event or activity.

By participating, you acknowledge that you have read and understood this disclosure regarding social media presence and pictures.
Signature of Responsible party (If client is their own guardian they must be the signer).

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Client Services Request