Community Programs FY26-27 Registration

Participant Name

First NameLast Name

Participant Date of Birth

Date

Participant Email

example@example.com

Participant Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Participant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Participant Gender

Participant Race/Ethnicity

Caregiver/Parent/Guardian

First NameLast Name

Email (if different from participant)

example@example.com

Phone Number (if different from participant)

Please enter a valid phone number.Format: (000) 000-0000.

Address (if different from participant)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

First NameLast Name

Relationship to Participant

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Media Consent I hereby authorize Triangle Disability & Autism Services, Inc. to photograph/video the Participant. The photographs/videos may be used for the following purposes (please check all that apply):

Publicity for Triangle Disability & Autism Services (ex. Training, news articles, press releases, Newsletter/E-Newsletter)

Internet: Triangle Disability & Autism Services Website or Social Media (Names will NOT be used on social media or our website)

My Products

Triangle Self-Advocacy Network

6:00-7:30pm; 2nd Tuesday of the month; Hillyer Memorial Church, 718 Hillsborough St, Raleigh AND 1:00-2:00pm; 1st Friday of the month – Zoom Meeting only

$25.00 Quantity

Petals with a Purpose

Wednesdays 1:15-2:15 pm; Seymour Center, 2551 Homestead Rd, Chapel Hill

$50.00 Quantity

Total

Credit Card

Choose all that apply:

Informed Consent and Acknowledgement I agree to participate in the community programs of Triangle Disability & Autism Services. I understand that taking part in this event is completely my choice. I understand that there is no anticipated risk or discomfort from participation in the program. I also understand that I may decline/refuse to participate in any part of the program and may withdraw my consent to participation at any time. I understand the venues where these events may be held cannot be held liable for any accident/emergency occurring during a Triangle Disability & Autism Services community program. I understand Triangle Disability & Autism Services community programs do not provide one-on-one supports/supervision.

Medical Release and Authorization In the event of a medical emergency involving the Participant, I give my permission to Triangle Disability & Autism Services to attempt to reach the emergency contact(s). If the situation necessitates, the staff members have my permission to provide first aid/CPR and/or seek emergency medical treatment for the Participant. I further agree to be responsible to all costs attached to this treatment. I release Triangle Disability & Autism Services and its staff members from any further liability.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Community Programs Registration- FY 26-27

My Products

Credit Card