Clubhouse Registration
Join the club, we are so happy you are here.
Name
*
First Name
Last Name
Have you been here before?
*
Yes
No
Age Group
*
Please Select
Child (0-12)
Teen (13-17)
Young Adult (18-30)
Adult (31-59)
Older Adult (60+)
What is your zip code?
*
Are you here for a program, walk-in visit or to volunteer?
*
Program
Walk-In Visit
Volunteer
How many people are in your group?
1
2
3
4
5+
Please select the program you are attending
*
Sing Sign Dance
Musical Learning with Lanny
KPOP Dance Class
Family Drum Circle
Sunday Funday
Family Stories
Adaptive Art with Alpha
Adaptive Art with Devereux
Harmony For Independence Music Workshop
Harmony For Independence Music Program
MS Luncheon
SPI Dinner
Young Adult Social
Other
Please type the name of the program
*
Please type the name of the event
*
Do you have a disability?
*
Yes
No
Please elaborate as you feel comfortable
Do you have any accommodation needs?
*
Yes
No
Please elaborate as you feel comfortable
Are you a client of Tri-Counties Regional Center (TCRC)?
*
Yes
No
Unsure
Please type your name and your service coordinators name
*
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Tell Us More (Optional)
This section is optional. The information you choose to provide helps us better understand our community, improve accessibility, and may be used in aggregate for grant reporting. If you'd prefer not to answer these questions, simply scroll to the bottom and click Submit. Thank you!
Participant Information
Email
example@example.com
Would you like to join our newsletter?
Yes
No
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Female
Male
Non-binary
Prefer not to answer
Other
Emergency Contact & Safety Information
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Participant
Please Select
Parent/Guardian
Family Member
Caregiver
Friend
Other
Allergies or Medical Considerations
Additional Information
Household Income Level
Please Select
Less than $25,000
$25,000–$49,999
$50,000–$74,999
$75,000–$99,999
$100,000+
Prefer not to answer
Race/Ethnicity
American Indian/Native
Asian
Black or African American
Hispanic/Latino
Native Hawaiian or Pacific Islander
White
Other
Prefer not to answer
Primary Language Spoken
Please Select
English
Spanish
American Sign Language (ASL)
Mandarin Chinese
Cantonese
Vietnamese
Tagalog
Korean
Japanese
Arabic
Russian
Farsi (Persian)
Other
Prefer not to answer
Please specify language:
Participant Waiver, Release of Liability, Emergency Contact & Photo/Media Release
Please Read Through Each Segment And Sign Below
Assumption of Risk
I understand that participation in Grace Fisher Foundation programs and activities—including, but not limited to, classes, workshops, camps, performances, community events, outreach programs, Art in the Park, and activities at the Inclusive Arts Clubhouse—involves inherent risks. These risks may include accidental injury, illness, property damage or loss, and other unforeseen circumstances.I certify that I (or the minor participant named above) am able to participate safely or that I have informed Grace Fisher Foundation of any medical conditions, accommodations, or support needs that may be relevant to participation. I voluntarily assume all risks associated with participation.
Release of Liability
In consideration of being permitted to participate, I, on behalf of myself (or the minor participant), my heirs, executors, administrators, personal representatives, and assigns, hereby release, waive, and hold harmless Grace Fisher Foundation, including its Inclusive Arts Clubhouse and all Foundation-sponsored programs, together with its directors, officers, employees, volunteers, instructors, contractors, agents, and representatives, from any and all claims, demands, causes of action, damages, losses, or liabilities arising out of or relating to participation in Foundation activities, including claims arising from ordinary negligence.This release does not apply to claims resulting from gross negligence, reckless conduct, or intentional misconduct, which cannot be waived under California law.
Emergency Medical Authorization
In the event of an illness or injury requiring emergency medical treatment, I authorize Grace Fisher Foundation staff or authorized representatives to obtain appropriate emergency medical care for me (or the minor participant) if I cannot be reached or am unable to provide consent. I understand that I am responsible for any medical expenses incurred.
Photo & Media Release
I grant Grace Fisher Foundation permission to photograph, video record, audio record, or otherwise capture my (or my child's) image, voice, artwork, or likeness during participation in Foundation programs or events. I understand that these materials may be used, without compensation, for educational, promotional, fundraising, marketing, public relations, social media, website, print publications, grant applications, annual reports, or other lawful organizational purposes. I waive any right to inspect or approve the finished materials and release Grace Fisher Foundation from any claims arising from their use.
Acknowledgment
By signing below, I acknowledge that I have carefully read and understand this Participant Waiver, Release of Liability, Emergency Contact & Photo/Media Release. I understand that I am giving up certain legal rights, including the right to bring certain legal claims, and I voluntarily agree to these terms. If participant is under 18: I certify that I am the parent or legal guardian of the minor participant named above and have the legal authority to sign this agreement on their behalf. I have read and agree to all terms of this document.
Participant Acknowledgement
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If under 18: Parent/Guardian Acknowledgement
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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