SNR Registration Form

SNR Participant Registration/Application Form
Participant Name*

First NameMiddle NameLast Name
Please take a picture of the person participating in the SNR Program.
Take Photo
Gender:*

MaleFemale
Date of Birth:*
Have you ever attended SNR? If so, when?*
What Program Are you interested in?*

Adult Life Group, $12 per day + activity fee, Monday-Friday 10-2 pm,Evening Group, $10-25 as noted on the monthly calendarYouth Camp All-Stars, $30 +activity fee, during no school days, 9-3 pmSpecial Events: SNR Prom, Luau, Valentines Dance, Christmas Party, Halloween Dance, etcSNR Sports: 6 week sessions, $25.00
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Email -program communication and billing*
example@example.com
Payee Email (if applicable)*
example@example.com
Payee Phone*
Please enter a valid phone number.
Agency Contact

AgencyCase worker
Agency Email
example@example.com
Agency Phone Number
Please enter a valid phone number.

Emergency Contact
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Family Physician*

First NameLast Name
Physician Phone*
Please enter a valid phone number.
Hospital Preference*
Insurance Carrier*
Policy Number*
Group ID #*
Have you ever been arrested or convicted of a criminal offense?*

YesNo
Are you a registered sex offender?*

YesNo
I consent to a background check.*

YesNo
Is there additional information you would like us to know?
One-on-One Policy

One-on-one status is determined by collaborating with parents, guardians, and case workers. SNR reserves the right to change one-on-one status if necessary. One-on-one staffing is arranged by the participant's family. SNR does not provide One-on-one staffing.
SNR defines one-on-one care as meeting one or more of the following criteria: 
1. The participant exhibits behavior problems such as aggression, explosive outbursts, run away. 
2. The participant cannot follow simple directions. 
3. The participant is not toilet trained. 
4. The participant will not remain in a group setting or wanders. 
5. The participant cannot perform basic care, walk w/o assistance, feed themselves, etc.

6. The participant has committed a criminal offense or is a registered sex offender.
Will your participant require one on one care as described above?*

YesNo
Program Communication
TeamSnap is a free app for communicating daily program scheduling and announcements. All parents, guardians, care providers, and support staff are required to use the app. This is how we manage attendance and transportation.

The participants' agency is responsible for providing SNR with the name and contact information of the staff member attending programs with your participant.

The agency staff member must use the TeamSnap app to communicate with SNR staff. Failure to adhere to these rules will result in removal from the program.
One-on-One Contact

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

Code of Conduct
Specialized Needs Recreation (SNR) offers participants opportunities to meet new people and try new activities in a fun and safe environment. There is a mandatory Code of Conduct for everyone involved to ensure that all participants, parents/guardians, staff, Board members, and volunteers enjoy the SNR experience. Your signature below is implied and informed consent that you have reviewed, understand, and will follow the Code of Conduct while participating in SNR events.

Code of Conduct:

·         All communication is conducted appropriately and respectfully. Inappropriate tones, foul language, unkind words, pushing, shoving, threats, comments in a sexual nature, and bullying are not allowed.

·         Handholding, kissing, or any form of sexual contact is not allowed.

·         Cell phones, handheld games, and other electronic devices are allowed; however, SNR is not responsible for any damage, loss, or theft. If the device contains offensive content or becomes disruptive, it will be put away until after the day’s activity. This includes inappropriate messages to others involved in SNR.

·         Jeans with excessive holes, shorts that do not reach to mid-thigh, graphic t-shirts with lewd, foul language or depict drugs/alcohol/sexual themes, or crop tops exposing the stomach, halter tops, and spaghetti strap (less than two inches tops) are not allowed. Clothing and hats are not to be shared.

·         Individuals shall behave in a manner that does not endanger their health and safety or that of others.

·         All participants are to show respect to both the property of SNR, and locations visited during an SNR activity. Stealing, damaging, or failing to care for the property of SNR and others is unacceptable.

·         Use of illegal substances, tobacco products, vaping devices, and alcohol is prohibited at SNR or SNR events.

·         Possession of any item considered a weapon (including, but not limited to, firearms, knives, pocketknives, and switchblades) is prohibited at all times.

·         Participation at SNR and its events is voluntary and violation of any of the above Code of Conduct may result in being asked to leave SNR for the day. At the discretion of SNR Staff and Board, a major violation can result in being barred from all future SNR activities.

IF A VIOLATION OCCURRED:

The individual will be redirected to a more appropriate behavior and receive a verbal warning. The incident will be discussed with them, their parent, and/or their guardian. The verbal warning will be documented in their file.

If the problem persists, or if a second but different violation occurs with the same individual, the individual will be redirected, and a written warning will be issued and documented in the individual's file, including but not limited to documenting the specifics of the behavior and the corrective action that took place.

If there is a third occurrence or if the individual's behavior threatens his/her immediate safety or that of any other individuals, SNR will have the right to ask the individual to leave (or be picked up immediately). The behavior will be documented, and the Executive Board will be notified and has the right to refuse further participation in all SNR programs.

Depending on the severity of the offense/behavior/incident, SNR has the right to expel the individual(s) from further participation in SNR at any time without following these procedures.

No refunds will be given to individuals who are removed from the program for violating the Code of Conduct.
I have read this “Code of Conduct” and fully understand it.*

I understandI have questions, please call to discuss

Participant Signature*

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Parent/Guardian/Care Provider Signature*

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Date

MonthDayYear
Date
Should be Empty:

SNR Participant Registration/Application Form

Please take a picture of the person participating in the SNR Program.

Emergency Contact

One-on-One Policy

Program Communication

Diagnosis

Payments and Policies

Household Financials

Liability Release Waiver

Code of Conduct