Registration form

Young Adult Participant Information

Address

Street Address

Parent Information

Caregiver (optional)

Does he/she exhibit any of the following behaviours?

BitingGrabbingKickingCursingHittingPulling HairN/AOther If other, specify:

Is he/she sensitive to any of the following?

LightNoiseTouchMovementN/AOther If other, specify:

Medical Information

What are your young adult's special needs?
Please list any allergies or medical conditions we should be aware of:

Emergency Contact

Consent

In case of a medical emergency requiring immediate emergency care, I authorize On My Own to call 911 and permit the paramedics to take my child to the nearest hospital if necessary. I authorize any adult acting on behalf of On My Own to hospitalize or secure treatment for my child. I permit my child's photos to be used by On My Own for marketing purposes. I hereby give permission for my child to attend On My Own field trips and classes and release them from all liability.

Signatures