T.E.A.M Dixon New Member Application
Thank you for your interest in TEAM Dixon. We are excited to have you and your family as part of our group of amazing people. Please complete the following information regarding your child. All information will be confidential, and will be used to best support him/her during events and activities.
Child's Full Name
First Name
Last Name
Child's Age
Child's School and Grade:
Parent/Guardian Name
First Name
Last Name
Contact Number
Email Address
example@example.com
Medical Provider Name
First Name
Last Name
Contact Number
Emergency Contact Name
First Name
Last Name
Contact Number
The emergency contact is:
Family
Friend
Other
Please explain your childs disability (ies), special needs, medical diagnosis:
*
Austim
Epilepsy/Seizure Disorder
Non-Verbal
F.A.S
Cerebral Palsy
Cognitive Delay
Down Syndrome
Other
Briefly explain your child's needs:
Does your child use a wheelchair?
Yes
No
Is your child hearing or visually impaired?
Yes hearing impaired
Yes visually impaired
Yes, both visually and hearing impaired
None
Is your child easily over-stimulated?
Yes
No
What are some qualities and character traits you would like to share about your child? i.e; temperament, interests, etc.
Does your child take medication on a routine basis?
Yes
No
If yes, please list them:
Does your child have any medication allergies?
Yes
No
Not Sure
If yes, please list them:
Does your child have any seizure disorder?
Yes
No
Not Sure
Give details regarding seizure disorder diagnosis.
Signature
Date
-
Month
-
Day
Year
Date
Back
Next
Permission and Agreements
From time to time, TEAM Dixon will update various media outlets with photos of TEAM activities with members and volunteers. This may include Facebook page, website, newsletters and publications, and sometimes the local newspaper. Do you give permission to have your child's photo used for TEAM Dixon publications and media outlets?
Yes I give permission
No I do not give permission to have my child's photo used for TEAM Dixon publications and media outlets.
Name of Child
First Name
Last Name
Parent Signature
Date
-
Month
-
Day
Year
Date
Back
Next
Volunteer Agreement
TEAM Dixon is a volunteer-run organization. We rely on donations, sponsorship, and the helping hands of many to keep things running and growing. We do not charge a fee to join, and do our best to offer all events and activities at no cost. By joining, you agree to do your part. Our complete volunteer agreement is included in the new member welcome packet. By signing you are agreeing to provide 5 hours of volunteerism per calendar year.
I understand and agree to 5 hours of volunteer time per calendar year.
I do not understand and will email to explain
Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Back
Next
Release of liability: Please read and SIGN below to complete your application.
Intending to be legally bound and hereby, the undersigned agrees and does hereby release from liability and to indemnify and hold harmless TEAM Dixon and it's volunteers and Board of Directors. This release is for any and all liabilities for personal injuries (including death) and property losses or damage occasioned by, or in connection with, any TEAM Dixon activity, sport, or event. Signature
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: