The Way Day Program Registration

The Way Day Program Registration

Complete this form to register for The Way Day Program and provide essential participant information.
Participant Identifying Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you an emancipated adult?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contacts
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Consent & Liability Release
General Consent & Acknowledgment

I certify that all information provided in this registration is true and accurate to the best of my knowledge.

I understand that participation in programs offered by Empowered Abilities, Inc. may include activities such as life skills training, recreational activities, crafts, community outings, and other program-related events.

I acknowledge that participation in these activities may involve inherent risks, including but not limited to physical activity, transportation, and community-based events.

I voluntarily give permission for the above-named participant to take part in all program activities.

Assumption of Risk & Liability Release

I understand and accept the risks associated with participation in program activities.

To the fullest extent permitted by law, I agree to release and hold harmless Empowered Abilities, Inc., Cicero Christian Church, its staff, volunteers, and affiliates from any and all liability for injuries, losses, or damages that may occur during participation, except in cases of gross negligence.

I understand that participants are responsible for their personal belongings, and the organization is not responsible for lost, stolen, or damaged items.

Medical Authorization

In the event of an emergency, I authorize Empowered Abilities, Inc. to seek and obtain necessary medical treatment for the participant.

I understand that I am financially responsible for any medical care provided, including emergency transportation and treatment.
Consent to Participate. By signing below, I confirm that:
Participant Name
Date

MonthDayYear
Date
Authorized Representative

First NameLast Name
Participation Consent & Liability Signature (Authorized Representative Signature)

Acceptance Conditions & Program Agreement
Empowered Abilities, Inc. is committed to providing a safe and supportive environment for all participants.

Program Participation

Participation in “The Way” program is based on the organization’s ability to safely and adequately meet each individual’s needs.

Empowered Abilities, Inc. reserves the right to decline or discontinue services if it is determined that appropriate care and support cannot be provided. All decisions are made on an individual basis by program leadership.

Incidents & Communication

Parent(s), guardian(s), caregiver(s), or appropriate agencies will be notified in the event of:

Serious illness or injury requiring more than basic first aid
Behavioral incidents that impact safety or program participation
Any significant concern affecting the participant’s well-being
Assumption of Risk

I acknowledge that participation in program activities involves inherent risks. I understand these risks and accept full responsibility for the participant’s involvement.

Emergency Pick-Up Requirement

If it becomes necessary for a participant to leave the program early for any reason (including illness, behavior, or safety concerns), I agree to arrange prompt transportation.

Ongoing Accuracy of Information

I agree to notify Empowered Abilities, Inc. of any changes to the participant’s medical, behavioral, or personal information as soon as I become aware of them.

Authorization to Share Information

I authorize the release and exchange of relevant information (medical, behavioral, or support-related) between Empowered Abilities, Inc. and appropriate caregivers, professionals, or agencies as needed to support safe and effective care.
Acknowledgement & Agreement
Date

MonthDayYear
Date
Participant Name

First NameLast Name
Participant Signature
Date

MonthDayYear
Date
Parent/Guardian/Caregiver Name:

First NameLast Name
Relationship to Participant:
Parent/Guardian/Caregiver Signature

Additional MedicalInformation & Authorization
Date of Last Tetanus Test

MonthDayYear
Date
Medical Alert Identification

If the participant has a medical alert bracelet or necklace, it is strongly recommended that it be worn during program hours.
Please Check All Boxes You Agree To

Emergency Care Authorization: In the event of illness or injury, I authorize Empowered Abilities, Inc. and Cicero Christian Church to: Provide basic first aid Contact emergency services (911) if necessary and share relevant medical information with paramedics or healthcare professionals. I understand that every reasonable effort will be made to contact a parent/guardian/caregiver. However, I acknowledge that immediate notification may not always be possible prior to emergency care being provided.
Participant Name
Date

MonthDayYear
Date
Parent/Guardian/Caregiver Name

First NameLast Name
Relationship to Participant
Parent/Guardian/CaregiverName Signature

The Way Day Program Registration

Participant Identifying Information

Parent/Guardian

Emergency Contacts

Mobility

Consent & Liability Release

Photo, Video, & Media Consent Form

Acceptance Conditions & Program Agreement

Additional MedicalInformation & Authorization

Standing Permission for Off-Site Activities and Community Outings