APSM - Life Skills Carnival Class - June

LIFE SKILLS & HOBBIES CARNIVAL CLASS REGISTRATION June 16th, 2025 - August 5th, 2025
Form Name

2025 Summer Life Skills Carnival Course
This summer, join the Life Skills & Hobbies Carnival - A hands-on, game-filled program where fun meets personal growth! Every Monday and Tuesday for 8-weeks, this 90-minute class turns essential life skills, like teamwork, communication, budgeting, and personal safety, into exciting carnival-style games and creative challenges. Participants will build confidence, real-world abilities, and a love for learning, in a safe, supportive, and festive environment where everyone is a winner!

June 16, 2025 - August 5, 2025

Mondays & Tuesdays: 2:30 PM - 4:00 PM (2x per week)

Ages 13+

16 Session Course $1,200.00 (Including all materials)

Registration Forms and Payment must be turned in prior to participation in any activity.

For Regional Center: Contact your service Coordinator and provide Vendor Code: PW8803, service code: 063. We need to receive Purchase of Service Approved.

Location: Adrian’s Place Santa Monica, 1806 Lincoln Blvd, Santa Monica, CA 90404

* This is an 16 Session course. Participants need to commit for all 16 sessions, as there is no refund if a class is missed.

* All participants must be self-sufficient or have an aide for support.

*This class is intended for participants who are motivated to learn new skills.

*We are Westside Regional Center Approved vendor. Vendor Code PW8803

If you have any questions, contact us at 310.581.8101 or info@AdriansPlaceSM.com.
A. Participant Information
Participant Name*

First NameLast Name
Participant Preferred Pronoun

She/HerHe/HimThey/Them
Participant Grade
Participant Date of Birth *

MonthDayYear
Date
Participant Phone Number*
Please enter a valid phone number.
Participant Email*
Address*

Street Address

Street Address Line 2

CityState

ZIP

C. Emergency Contact Information

Please list the name and contact information to contact in an emergency/authorized to pick up your participant.
Emergency Contact 1
Contact Name*

First NameLast Name
Phone Number *
Please enter a valid phone number.
Type of Phone Number

Mobile PhoneWorkHome
Is this Emergency Contact 1 authorized to pick up the participant?*

YesNo
Relation to the Participant

D. General Intake Information
Please list any physical limitations of your participantwhich we should be aware of?
Participant General Information
How does your participant communicate? (i.e. verbal, device, sign, please specify)?
Will your participant be attending with 1 on 1 support? (Please note: 1:1 support is required if participant needs help managing behavioral challenges or is not bathroom independent)*

YesNo
If attending without 1:1 support, can the participant arrive and leave independently?*

YesNo
Tell us about your Participant
Please check any that apply:*

Needs supportAble to participate independently
Let us know if there is any other additional information we should to know regarding your participant.

PROMOTIONAL CONSENT Do you consent to receive updates on classes, programs, and events from Adrian’s Place Santa Monica?*

YesNo
PHOTO AND VIDEO RELEASE Do you consent for Adrian’s Place Santa Monica to use, copy or display your participant’s photograph or video recorded image to promote Adrian’s Place through advertisements on websites, television, News releases, brochures, pamphlets or others.*

YesNo
I. Adrian’s Place Policy and Procedure

Health and Safety: If your participant is experiencing any symptoms of illness, please keep them at home and notify us of their absence.

Attendance: In the event that your participant will be absent, please notify us.

Support Aide: If your particpant requires additional support, you will need to provide a one-to-one support aide. Participants in need of one-to-one support must arrive with support or they will not be permitted to participate in the class.

Bathroom: Due to our program design and liability coverage, we are not permitted to assist participants in the restroom. Therefore, ALL participants must be bathroom independent in order to attend to our class or must attend with one-to-one support.
Form of payment *
** For Regional Center, please provide which regional center, name of your Service Coordinator, e-mail, phone number, and UCI# of participant*
*Self Determination please provide FMS contact information. *
Refunds: There are NO REFUNDS or credits for missed classes.*
Registration Forms and Payment must be turned in before participation in any activity..*

I acknowledge
Signature required by guardian for program enrollment to register for the course.*

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ADRIAN’S PLACE ASSUMPTIONOF RISK / RELEASE OF LIABILITY / INDEMNIFICATION AGREEMENT
As consideration for permission to enter onto the real property located 1806-1808 Lincoln Blvd., Santa Monica, CA 90404 (“Property”) to attend various gatherings, including but not limited to, time before and/or after an activity, unorganized free time, participation of any organized recreational, educational or therapeutic activity, movie nights, potlucks or other similar social gatherings organized by or in association with Adrian’s Place Santa Monica, LLC, (“Company”) the undersigned acknowledges, appreciates, willingly and with full knowledge, agrees that:

1. Entering onto the Property inherently includes possible dangers, including but not limited to personal injury, and possible death, damage to personal property or exposure to and illness from infectious diseases, including but not limited to MRSA, influenza, and COVID-19. While rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,

2. I, ON BEHALF OF MYSELF OR FOR THE MINOR IDENTIFIED BELOW, KNOWINGLY AND FREELY ASSUMES ALL SUCH INHERENT RISKS, both known and unknown, EVEN IF ARISING FROM THE ACTIVE OR PASSIVE NEGLIGENCE OF others, and assumes full responsibility for participation; and,

3. I recognize the importance of complying with, and I will ensure that I or the Minor fully complies with, any applicable laws, policies, rules, instructions, and posted warnings entering on to the Property. Minor and I understand that if we believe anything on the Property may be unsafe, we will advise a Company representative and may refuse to enter on the Property. Entering onto the Property and remaining on the Property shall constitute consent to these terms.

4. On behalf of myself or the Minor, HEREBY RELEASE AND HOLD HARMLESS the Company, directors, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE ACTIVE OR PASSIVE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law. Further I or on behalf of the Minor agree to defend the Company for any and all claims, suits, allegations or action brought against the Company arising out of, relating to or based in any way out of such presence on the Property, regardless of the doctrine of comparative fault.

5. I agree that if any portion of this contract is held invalid, the remainder will continue in full legal force and effect. I understand and agree that the law of the state of California shall apply. I agree that all disputes shall only be brought in the State Court of California without regard to the choice of law doctrine. I agree to the personal jurisdiction of California to adjudicate any such dispute.
By Signing here, you agree to ADRIAN’S PLACE ASSUMPTIONOF RISK / RELEASE OF LIABILITY / INDEMNIFICATION AGREEMENT*

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LIFE SKILLS & HOBBIES CARNIVAL CLASS REGISTRATION June 16th, 2025 - August 5th, 2025

A. Participant Information

B. Parent/Guardian Information

C. Emergency Contact Information

D. General Intake Information

ADRIAN’S PLACE ASSUMPTIONOF RISK / RELEASE OF LIABILITY / INDEMNIFICATION AGREEMENT