Participant Information Form

  • Participant Information Form

  • It is the responsibility of the participant, parent, or legal guardian to keep this information current. This information needs to be completed when you begin your membership. If this information has not been completed, you will be unable to participate in any activity or event. All information will be kept confidential.

    ONE FORM PER PERSON

    DO NOT PRINT THIS FORM AND THEN COMPLETE IT. 

    COMPLETE THIS FORM ONLINE AND WHEN ALL REQUIRED FIELDS ARE COMPLETED, CLICK THE GREEN SUBMIT BUTTON AT THE BOTTOM.

  • Membership

  • Membership Rates*
  • Membership*

  • Renewal Membership

    Visit https://schedulesplus.com/lifemc/kiosk/ log-in with your phone and pin number and pay your membership fee.  You can also mail or drop off your membership fee payment.

  • Membership Payment*

  • Your membership will not be valid until payment has been received.

  • General Information

  • Format: (000) 000-0000.
  • I have a cell phone:*
  • Format: (000) 000-0000.
  • Birthday*
     - -
  • Gender*
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  • Have you ever been convicted or charged with a criminal offense other than minor traffic violations?*

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Guardianship Information

  • I am my own guardian*
  • Format: (000) 000-0000.

  • Case Manager Information

  • I have a Case Manager*
  • Format: (000) 000-0000.

  • Demographic Information

  • Household Income*
  • Ethinicity*
  • Living Situation*
  • Format: (000) 000-0000.
  • Times that work best for me to attend activities*
  • Days that work best for me to attend activities*
  • These things might prevent me from participating in activities at LIFE Mower County*

  • Health Information

  • Health History*
  • Physical Limits*
  • Self-Administer Medications*
  • Need verbal reminders to take medications*

  • Life Skills Information

  • Does the member require 24 hour supervision?*
  • Can the member be left alone?*
  • Member can leave the LIFE Mower County group?*
  • Does the member need to have staff with him/her at LIFE Mower County programs?*
  • Can the member manage his/her own money?*

  • Behavior Information

  • Behavior Information*

  • Consent / Permission

  • Medication Assistance - I give permission to LIFE Mower County to assist the Participant with any prescription or over the counter medication(s) their physician has approved or prescribed:*
  • Photos: ​I give permission to LIFE Mower County to use my likeness, name, voice, and words in television, radio, film, newspaper, magazines and any other media (www.lifemowercounty.org and www.facebook.com/lifemowercounty) in any form for promotional or educational purposes.*

  • Consent and Release of Liability

    I know that participation is a privilege. I know of the risks involved in participation and understand that injury may occur and choose to accept such risks.

    I voluntarily accept any and all responsibility for my own safety and welfare while participating in programs at LIFE Mower County, with a full understanding of the risks involved. I release and hold harmless LIFE Mower County and its employees from any and all responsibility for any injury or claim resulting from such participation and agree to take no legal action against LIFE Mower County because of any accident or mishap involving my participation. I further authorize the use or disclosure of my individually identifiable health information should treatment for illness or injury become necessary.

    I understand that this authorization is voluntary and that I may revoke it at any time by submitting the revocation in writing to LIFE Mower County. 

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