2025-Take Flight Club(TFC) Application

TAKE FLIGHT CLUB APPLICATION 2025

Social Clubs for teens and young adults with autism. A division of 3 Bluebirds Farm.
Before continuing with this application please understand that our club is to help guide facilitation of social skills, communication and interactions amongst other participants, staff and volunteers. Individuals attending TFC should have the desire to work on these things. We do not want this to be a forced experience. In order to promote intentional engagement with participants all electronic devices (including cell phones), stuffed animals, books along with any and all other things brought by participants that could be used to distract from the group or focus on isolated activities will need to be put away in a pocket, bag or an available cubby space if being used inappropriately or prohibiting engagement with the group. Submitting an application does not guarantee acceptance — this is a review-based application process, and all participants must meet our eligibility criteria.
Name (TFC Participant):*

First NameLast Name
Preferred Name:
Participant Date of Birth*

MonthDayYear
Date
How did you hear of 3 Bluebirds Farm?
Sex*
Please upload a recent picture of your child: *

Browse Files

Cancelof
Child's Current Age:*
Child's Emotional Age:*
May be different than child's chronological age
Name of School child attends:*
The child is living with:*

ParentGroup HomeRelativeOther
Name of person child is living with:*

First NameLast Name
Phone number of person child is living with:*

Area CodePhone Number
Email of person child is living with:*
example@example.com
Address of person child is living with:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Our goal is to provide a social club that is fun and meaningful for each participant. Over the years, we have held several social club events that have provided opportunities to observe and consider how well we are meeting our goals and how participants are responding. Our observations have led us to understand that we can provide a better, more enjoyable experience for participants by organizing activities into two different groups. By offering two groups, we are able to tailor activities more specifically so that individual participation in each teen/young adult might increase and, as a result, be more enjoyable. Therefore, two separate Take Flight Club programs were being offered in order to better accommodate all participants. However, due to lack of participation, we have had to make the sad decision to discontinue Take Flight Clubs for Group B.

Your teen or young adult must meet Group A Criteria in order to participate in Take flight clubs:

We understand that you know your child the best and we feel confident that you will know whether or not your child will gain a meaningful experience from a social club for Group A participants. However, we fully understand that there are individuals who "fall in the middle," and if you need our guidance in helping you with your decision, we are more than happy to help. If you have questions or need additional information, please don't hesitate to give us a call.
Group A will be meeting on various Saturdays at various times in various places in the community.

GROUP A: Criteria for Group A Participants (Child, teen or young adult on the autism spectrum demonstrates ALL of the following):

	YES
Does not require a 1:1 aide
Does not eat inedible objects (Pica)
Ability to participate in activities without disruptive behaviors that interrupt the event
Willingness & ability to participate in group activities that require conversational skills
Ability to follow verbal directions
Usually is able to verbalize wants and needs
Independence in all daily living skills (toileting, eating, dressing)
Ability to remain in open space without wandering or running

GROUP B: Criteria for Group B Participants (Child, teen or young adult on the autism spectrum demonstrates SOME or MOST of the following):

	YES	NO
Is non-verbal, or mostly non-verbal, and does not consistently respond to requests or instructions
Is unable to participate in a reciprocal conversation with others and/or answer open-ended questions
Needs 1:1 supervision at all or most times
Unable to verbalize wants and needs
Tendency to wanter or run away
Noise sensitivity, or tendency to become easily over-stimulated or stressed
Tendency to have "melt-downs"

Based on the above criteria, do you believe your child would enjoy and have a meaningful experience as a Group "A" participant?*

YesNoUnsure, please see notes.
Notes
Has the child attended any 3 Bluebirds Farm activities before?*
What are your child's interests?*
What are your child's strengths and talents at home, at school, and in the community?*
In what areas do you feel that your child needs extra help?*
What is your child's learning style? How does he/she best learn?*
Have you and your family set goals for your child's progress socially? If so, what are your goals for him/her?*
What types of behavior does your child demonstrate when under stress? In other words, what behaviors should we look for?*
If your child is upset, what is the best way to help him/her through it?*
How does your child deal with frustration? How do, or don't they communicate stress or frustration at home or with peers?*
What do you most admire about your child?*
If your child had an hour of free time, how would they most likely use that time?*
Is your child shy, sensitive or nervous about anything we should be aware of?*
What concerns (if any) do you have about your child participating in the Take Flight Club?*
Please write down anything else you'd like us to know about your child to help make his/her involvement in the Take Flight Club a successful experience.
Child's favorite snack
Child's favorite color
Safety concerns (Crossing streets, elopement, eating inedible objects, etc.)?*
Does your child have a 1:1 aide at school?*

YesNo
Does your child have seizures? (If yes, please provide us with a seizure protocol from your physician)*

YesNoOther
Is your child mostly verbal? If not, does he/she have a means of communication?*
Child's Swimming Ability:*
Is your child incontinent?*

YesNo
Is he/she able to use the bathroom without assistance?*

YesNo
Any fears or triggers we need to be aware of?*
Dietary restrictions or Allergies (If none, type "none"):*
Illnesses/Medical Complications (If none, type "none"):*
Disabilities/Limitations besides autism (If none, type "none"):*
Any specific activities to be encouraged?
Any specific activities to be restricted?

Explain any unusual family circumstances that make Social Clubs especially important for the child:*

	Often	Sometimes	Not At All
Agressiveness
Bedwetting
Biting
Hyperactive
Learning Disabilites
Nightmares
Night Terrors
Runs Away
Sexually Acting Out
Steals
Tantrums/"Meltdowns"
Lying
Withdrawn

Please elaborate on any of these selections above or add anything else we may have missed:

Child's Sensory Seeking Behaviors*

	Yes	No
Does the child create a lot of noise?
Does the child crave bright lights, colors or busy pictures?
Does the child like to crash into walls, people, etc.?
Does the child use a lot of force when touching, hugging or with high fives?
Does the child stomp feet when walking or kick feet when sitting?
Does the child like to be under heavy blankets to sleep?
Does the child love to spin or swing?
Does the child like to hang upside down?
Is the child unaware of messiness or hands or face?
Does the child like to get dirty?
Does the child like bare feet?

Please elaborate on any of the selections made above or add anything else we may have missed:

Child's Sensory Avoiding Behaviors*

	Yes	No
Does your child avoid or dislike bright lights, colors or busy pictures?
Does the child dislike heavy backpacks or heavy blankets?
Does the child become very upset when bumped or pushed, even by accident?
Does the child dislike spinning or doing somersaults?
Does the child get dizzy easily?
Does the child dislike being upside down?
Does the child dislike being picked up or moved?
Does the child dislike when his/her feet leave the ground?
Does the child wipe kisses off cheeks?
Does the child dislike tags in clothing, seams in socks, etc?
Is the child sensitive to certain types of fabrics in clothing and/or sheets?

Please elaborate on any of the selections made above or add anything else we may have missed:
Emergency Contact Information

Please list an individual other than the previously named parent/guardian that the participant lives with who may be called in case of emergencies AND are permitted to pick up your child. We require a written request to modify any of the emergency contact or authorized pick-up information provided below.
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*

Area CodePhone Number
Emergency Contact's Relationship to child:*
Doctor's Name: *

First NameLast Name
Doctor's Phone Number:*

Area CodePhone Number
Dentist's Name:*

First NameLast Name
Dentist's Phone Number*

Area CodePhone Number
Insurance Company Name*
Subscriber/Member ID#*
Group #*
MEDICAL RELEASE FORM: I (we) the undersigned parent(s) or legal guardian of the above participant, do hereby authorize and consent to any medial/dental, x-ray examination, medical or surgical diagnosis and treatment and emergency hospital care which is deemed advisable by and it to rendered under general or special supervision of any member of the medical staff and emergency room staff licensed under the staff of any acute general hospital/dentist holding a current license to operate a hospital from the State of North Carolina Department of Public Health. It is understood that this authorizes and empowers the aforementioned physician in the exercise of his/her best judgment to render care which he/she may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.
Signature of Parent/Guardian*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Above Signer's Relationship to child:*
PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS

I hereby give the 3 Bluebirds Farm staff permission to administer the following products according to manufacturer's instructions, or as otherwise specified.

I trust the staff their best judgment as situations arise, and if in doubt, he/she can call for verification.

Please check Yes or No for the medications listed below.

Medications

	Yes	No
Sunblock
Insect Repellent
Lip Blam
Tylenol
Antiseptic Ointment
Band-Aids
Anti-Itch Cream
Antihistamine (Benadryl)
Ipecac Syrup

Please list any over-the-counter medications NOT included in the list above allowed to be administered:
Please make note of any known food and/ or environmental allergies that your child may have:
If your child has any allergies please provide special instructions as to treatment of a reaction:
Parent or Legal Guardian's Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
PLEASE NO ELECTRONIC DEVICES, PHONES, MONEY, OR FOOD (unless your child is on a special diet). These items are not needed and will be highly discouraged at Take Flight Clubs so that your child can focus on social skills. Please prepare your child ahead of time. Please input the 3 Bluebirds Farm main line number into your phones in the event you need to contact your child in case of an emergency: (919) 629-7500. On the occasions that activities are held off-site the number will be forwarded to the cell phone of a staff member at the activity location.
Release of Liability and Assumption of Risk Form

Official Waiver for 3 Bluebirds Farm Take Flight Club Activities: Please Read Carefully. This is a Release of Liability and Assumption of Risk
Official Waiver for 3 Bluebirds Farm Take Flight Club Activities:

OFFICIAL RULES AND DISCLAIMER: In consideration for the opportunity to participate in any and all of the 3 Bluebirds Farm Take Flight Club Activities (“Activities”), I agree as follows for myself, and any who participate and/or attend with me:

1. I, the undersigned am the parent/legal guardian of the below listed individual who is participating in the 3 Bluebirds Farm Take Flight Club Activities. By signing this Release of Liability and Assumption of Risk, I certify that I am the adult with legal responsibility for this participant and freely enter into this agreement on his/her behalf.

2. I hereby waive and release, for myself, my child, my heirs, executors and administrators, any and all rights, claims, liabilities costs, injuries, damages and causes of action whatsoever I may have against 3 Irish Jewels Farm, its affiliates and the Activities operators and sponsors and each of their respective officers, directors, employees and agents (the “Activities Parties”) relating to or arising from my/our participation in the Activities, including but not limited to personal injury.

3. I recognize the Activities have inherent risks of injury and I hereby knowingly and freely assume that risk, on behalf of myself, and my child. I also recognize that. If I, or my child causes injury to any person or damage to any property while participating in the Activities, I hereby indemnify and hold harmless 3 Bluebirds Farm from and against any and all claims, suits, actions, losses, damages and expenses related to or arising from such injury or damage.

4. I understand that pursuant to the 3 Bluebirds Farm Take Flight Club Activities there may be times that transportation is provided for the child/participant to attend field trips or other activities. I hereby give my consent to such transportation and assume all risks involved in such transportation. I hereby waive any and all costs, injuries, claims, damages and causes of action or other liabilities that may arise out of such transportation. I further acknowledge and agree that I will indemnify and hold harmless, 3 Bluebirds Farm and the Activities Parties from any liability for injuries or damages arising out of such transportation.

5. Photography/Audio - I hereby give my consent on behalf of myself and my child to 3 Bluebirds Farm and its affiliates to use my name and photographs, video and film (“Photos”) of me before, during or after the Activities in advertising and promotional materials for 3 Bluebirds Farm, including but not limited to the Internet, without compensation. I agree that no advertising or other material need be submitted to me for approval. I agree that all Photos of me used by 3 Bluebirds Farm and its affiliates are owned by 3 Bluebirds Farm and they may copyright material containing same.

Kymanox Industry and its employees continue to be generous and active participants with 3 Bluebirds Farm. To share the impact they are making with us to the community the Kymanox marketing department photographer requests to share photos on the organization's social media. With your permission, a photo that includes your child will be used.

I understand that my child's name will NOT be listed or advertised without parent/guardian permission.

I hereby release, discharge, and agree to save harmless the Activities Parties from any liability, including, without limitation, any claims for libel or invasion of publicity/privacy, by virtue of any use of mine or my child’s name and/or Photos, including, any alteration of such Photos, whether intentional or otherwise.

I have read and understand this Release, and declare all information is truthful and accurate.
SICK/COVID-19 GUIDELINES

A participant should not attend TFC when he/she has:
- Nausea or vomiting, or has vomited during the night
- Diarrhea
- Frequent coughing or sneezing, colored nasal discharge
- Evidence of a communicable disease such as a rash or unusual sores
- A temperature of 100 degrees or above
- Sore throat
- Unusual watery, burning, red or crusted eyes
- An unexplained, contagious, or oozing rash
- Head lice
  
  Participants should be free of these symptoms (without the use of medication) at least 24hrs prior to attending an event.
* Any participant testing positive or had direct exposure to an individual that has tested for the flu or Covid-19 within 5 days of an event may not attend*

*Please note that we may make addendums to our policy as needed for the health of participants, volunteers, and staff.
Parent Directory Information

3 Bluebirds Farm is a community which all families with children receiving services from our organization are a part of. The Community Directory will aim to facilitate positive communication among the participants and their families. The directory will include participant name along with parent/guardian names and e-mail addresses. This information will only be accessible through the password-protected "Current Families" section on our website.
Which Program does your child participate in?

Camp Bluebird (Track-Out)Camp Bluebird (Summer)Take Flight Club
Signature of Parent/Guardian*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Enter the message as it's shown*
Should be Empty:

TAKE FLIGHT CLUB APPLICATION 2025

Emergency Contact Information

Release of Liability and Assumption of Risk Form

Parent Directory Information