Language
English (US)
Spanish (Latin America)
EA Clubs Registration
Submit this form to register for any of our North or West EA Clubs. Please make sure to review our consumer safety/success requirements and payment requirements prior to registering: https://www.embracingabilities.com/ea-clubs/.
Which club would you like to register for? (Select All That Apply)
Social Club (Ages 20-35 - North Location - PRIVATE PAY ONLY)
Consumer's Name
*
First Name
Last Name
Email
*
example@example.com
Are you a current client of Embracing Abilities?
*
Please Select
Select One
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Client's Guardian Name/Contact Person
*
First Name
Last Name
Client's Guardian/Contact Phone Number
*
Funding Source
*
Private Pay
EA Clubs: Social Club - By checking, I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.
*
Participant is appropriate for a 6:1 and 8:1 group setting ratio.
Participant is appropriate for a community setting.
Participant can participate in a group activity with little to no staff assistance/prompting.
I understand EA Clubs has a $20 per meeting fee that is due upon arrival of each club meeting.
Participant is 16+ years of age.
Participant is choosing to attend and participate in EA Club events.
EA Clubs: Cooking Club - By checking, I agree the participant meets all of the REQUIREMENTS FOR SAFETY AND SUCCESS listed here.
*
Consumer is able to hear, comprehend, and apply basic safety directions to activity.
Consumer is able to physically use/hold kitchen tools/appliances independently.
Consumer will utilize these skills independently in the future.
Consumer is able to participate appropriately in a small group setting.
I have read the requirements for safety and success and agree that this consumer is appropriate for the selected edition. I understand that placement into EA Clubs will be reviewed by the intake team to ensure the safety and success of all participants and the final enrollment.
*
Please sign above
How did you hear about us?
Waiver Case Manager/Pick List
Facebook
Friend/Family Member
Caregiver
Current Embracing Abilities Family
Google
Drive by
Other
Submit
Should be Empty: