• SNR Participant Registration/Application Form

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

  • Gender:*
  • What Program(s) are you interested in? Detailed program information is found on our website*
  • Does the participant have a court-appointed legal guardian? If so which type?

  • If the participant is a minor, they turn 18 on    

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Have you ever been arrested or convicted of a criminal offense?*
  • Are you a registered sex offender?*
  • I consent to a background check.*

  • 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?*

  • All One-on-One staff are required to sign the One-on-One Code of Conduct. Link is below:

    https://form.jotform.com/253167448104153

  • Program Communication

  • SNR requires participants to RSVP to programs and events. Parents, caregivers and guardians are required to RSVP in order for their participant to attend. This ensures proper staffing and transportation.

  • Diagnosis

    Answer yes or no to all that apply and provide additional notes in the box below.(example: easily fatigued, wanders, feeding or toileting assistance, etc).
  • ADD*
  • ADHD*
  • Amputee/Adaptive Equipment*
  • Autism*
  • Blindness*
  • Brain Injury*
  • Cerebral Palsy*
  • Deaf*
  • Diabetes*
  • Down Syndrome*
  • Epilepsy*
  • Heart Problems*
  • Learning Disability*
  • Mental Illness*
  • Multiple Sclerosis*
  • Williams Syndrome*
  • Non-Verbal*
  • Seizures*
  • Wheelchair Restricted*
  • Is your participant required to carry an EpiPen?*

  • Payments and Policies

    SNR is a non-profit 501(c)(3) that was created to develop, support, and enhance programs of recreation, leisure, and enrichment for individuals with special needs. We fund this program with grants and donations, both public and private, and yet that still does not cover 100% of our operating costs. Every effort is made to keep the cost of this program at minimal for our participants and their families. The following is our payment policy; by initialing you are committing and agreeing to the SNR guidelines and policies.  

  • Household Financials

    Data collected from the following questions could improve our eligibility for grants, donations, scholarship eligibility, and the Community Reinvestment Act. 
  • Please check all that apply:*

  • Liability Release Waiver

  • I am aware that participation in recreational activities may have obvious and latent hazards, which may be caused by my actions or inactions, by the actions of others participating in the event, or by conditions in which the events take place. I fully accept and assume all such risks and all responsibility for losses, costs, and/or damages I may incur because of my participation. I also understand that Specialized Needs Recreation has no medical insurance to cover medical expenses; all medical costs are my responsibility.   
      
    I hereby release, discharge, and hold harmless Specialized Needs Recreation all staff, directors, administrators, and volunteers in any/all programs sponsored by Specialized Needs Recreation. I also release, discharge, and hold harmless, any person transporting me before, during and/or after such activities.  
      
    If I should need emergency medical treatment during my participation in Specialized Needs Recreation activities and I am not able to give my consent or make my arrangements for that treatment, I authorize Specialized Needs Recreation to take whatever measures are necessary to protect my health and well-being, including, if necessary, hospitalization.  
      
    I also permit pictures and/or videos of myself to be used by Specialized Needs Recreation and any other group they approve of for public relations purposes.  

  • I have read this Liability Release Waiver, Assumption of Risk.*

  • 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.   

    No PDA at SNR Activities (this goes for guy/girl, girl/girl, guy/guy)

    o Brief hugs only

    o No sitting on laps

    o No kissing

    o No arm around the shoulder

    o One person per chair

     

    1. 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.


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

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

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


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


    6. Jeans with excessive holes, shorts that do not reach mid-thigh, graphic t-shirts with lewd, foul language or depicting 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.


    7. 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.


    8. 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.

     

    IF A VIOLATION OCCURS: 

    The individual will be redirected to 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.*

  • Consent to Treat


  • I, the undersigned participant, parent, or legal guardian, authorize Specialized Needs Recreation (SNR), its employees, volunteers, and authorized representatives to obtain or provide appropriate first aid and emergency medical care for the participant if an illness, injury, or medical emergency occurs while participating in SNR programs or activities.

    I understand that reasonable efforts will be made to contact the emergency contact(s) listed on this form before or as soon as reasonably possible following any emergency. If emergency medical treatment is deemed necessary and I cannot be reached, I authorize SNR to secure medical treatment, including transportation by emergency medical services, as recommended by qualified medical personnel.

    I understand that I am financially responsible for any medical care, transportation, or related expenses incurred as a result of such treatment.

    I certify that the information provided regarding the participant's medical history, allergies, medications, and emergency contacts is accurate and complete to the best of my knowledge. I agree to notify SNR promptly of any changes to this information.

    By signing below, I acknowledge that I have read, understand, and voluntarily agree to this Consent to Treat authorization.

     

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