Club Membership Registration Form

Austen's Autistic Adventures Membership Registration

Complete the form below to sign up. After receipt of submission, a representative from Austen's Autistic Adventures will be contacting you to set up an interview with you and your child via Zoom. This meeting is required prior to attendance. Both a parent (or legal guardian) and potential member must attend this meeting before your Adventures begin!
MEMBERSHIP

Membership is available to anyone 16 years of age or older. An officer of the company will decide if your member needs to attend with an aid to events.

When completed, please submit for to jamie@autismadventures.org
Member Name

First NameLast Name
Your Name:
E-mail
Phone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date:

MonthDayYear
Where did you hear about us?

A friend or colleagueGoogleFacebookNews ArticleInstagram
PARTICIPATION POLICY : We are not equipped to manage significant behavioral issues. We will work with you as best we can, but if your child presents any danger to him or herself, our other participants, or our volunteers, we will need to discontinue your child’s participation in the program. WE RESERVE THE RIGHT TO DISCONTINUE MEMBERSHIP IN AUSTEN'S AUTISTIC ADVENTURES AT OUR DISCRETION AT ANY TIME AND FOR ANY REASON. EVENT FEES AND MEMBERSHIP DUES ARE NON-REFUNDABLE.
I have read, understood, and accepted the PARTICIPATION POLICY for membership.
Family Demographics

Black or African AmericanWhite or CaucasionHispanic or LatinoAsianOtherPrefer not to answer
What is your estimated household income before taxes?

$0-$19,000$20,000-$34,999$35,000-$49,999$50,000-$74,999$74,000-$99,999$100,00-or morePrefer not to answer
Which option best describes your child's communication skills?

Daily use of adaptive technologyGestures, sign language2-3 word utterances4+ wordsFull sentencesOther
Are you interested in job training?

YesNo
Additional details about your child's communication.
Mom/Dad: Describe your relationship with your child.
Siblings? Please describe relationships with brothers/sisters
Pets? Likes, dislikes, allergies, fears.
Schools Attended/Feelings about school
Work or volunteer experience, if any. Feelings about work/volunteerism.
What signs might indicate that your child is uncomfortable or headed towards a meltdown?
Food. Please list any allergies or special dietary considerations.
Medications. Please list. We cannot give medications to participants.
.
Medicine Acknowledgement

I understand that Austen's Autistic Adventures cannot administer medication to my child. If medication needs to be taken during an event, a family member or designated caregiver must administer any medications, both prescription and over-the-counter.
What strategies do you use to calm agitation?
Whom should we contact if member cannot continue at an event and must be picked up? Please list at least three options in order of preference.
Likes. What does your child enjoy doing? *We use "likes" both to create events and explore job opportunities.
Dislikes. Including to but not limited to activities (Dislikes sports, for example). Dislikes also can include things like loud noises or crowds.
RELEASE OF LIABILITY

AUSTEN’S AUTISTIC ADVENTURES

To the best of my knowledge, I am in good physical condition and fully able to participate in events with Austen’s Autistic Adventures. I am fully aware of the risks and hazards connected with the participation in these events, including physical injury or even death, and hereby elect to voluntarily participate in said events, knowing that the associated physical activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OR LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or loss or damage to property owned by me, as a result of participation in this program.

I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, Austen’s Autistic Adventures., their volunteers, officers, servants, agents, and employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, while participating in physical activity, or while on or upon the premises where the program is being conducted.

It is my expressed intent that this release and hold harmless agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVE, DISCHARGE, and CONVENTION TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be constructed in accordance with the laws of the state where Austen’s Autistic Adventures events takes place.

In signing this release, I acknowledge and represent that I HAVE READ THE FORGOING Waiver of Liability and Hold Harmless Agreement, UNDERSTAND IT AND SIGN IT VOLUNTARILY as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreements have been made; and I EXECUTE THIS RELEASE FOR FULL, ADEQUATE AND COMPLETE CONSIDERATION FULLY INTENDING TO BE BOUND BY SAME.
I have read and agreed to the above terms.
PHOTOGRAPHY, FILM, OR VOCAL RECORDING RELEASE

AUSTEN’S AUTISTIC ADVENTURES

Note: I authorize this release based on the following conditions.

• These records become the property of Austen’s Autistic Adventures or its representatives.

• This release is given without promise of compensation.

• This release is effective until terminated by a retraction in writing from the person

granting this authorization.

• The parent/legal guardian and the participant do release to Austen’s Autistic Adventures any right, title and/or interest of any kind they may have in the records produced.

• I hereby grant to Austen’s Autistic Adventures the right and authority to photograph, film and/ or record vocally.

These records may be used for promotional, publicity or teaching purposes and may be published in mass media publications, on the intranet or Internet sites, or shown on television or movie presentations.

The participant’s and family’s name may be used. This release is effective until revoked in writing by the undersigned. Such revocation shall only be effective to prevent any expanded future use of the records
Photography, Video, and Recording

I agree to allow my child to be photographed and videotaped for the purpose of promoting Austen’s Autistic Adventures.
Membership dues: $250 per year.

Existing member dues are payable by Feb 28th each year.

New Members: Year begins from date of acceptance into the program and will renew on that date each year. If existing members do not pay by the annual due date of Feb 28th, your new payable dues date will be from the day payment is made.

NO ONE MAY PARTICIPATE UNLESS LIABILITY RELEASE FORM IS COMPLETED AND DUES ARE PAID.

Photography release is optional and may be revoked at any time if so requested, in writing.
Type of Membership

New Member (Either someone who has never participated or a former member inactive for more than one year) ·Existing member
Once you submit your application, we will contact you shortly to complete a short interview via Zoom. We ask that you and your child both be present.

If you choose to join, you will then be admitted to our private "Event" page on Facebook.

SUBMIT COMPLETED APPLICATION TO: jamie@autismadventures.org

Thank you!
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Austen's Autistic Adventures Membership Registration