Name of Applicant *

Name of youth participant.

First Name

Last Name

Date of Birth *

Youths date of birth.

MM

DD

YYYY

Phone *

Youths phone number.

(###)

###

####

Mobile Phone

The participants mobile phone number.

(###)

###

####

Address *

Address of youth participant.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Resides With *

Please select whom the participant resides with.

Mother

Father

Guardian

Other please explain:

Diagnosis *

Please select the youth participants diagnosis.

Autism

ADD

ADHD

Downs Syndrome

FASD

OCD

ODD

PDD

Tourette's Syndrome

Other please explain:

Primary Contact

Name of primary contact (if not the participant).

First Name

Last Name

Address

Primary contact address, (if different than the youth participants).

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Primary contacts phone number.

(###)

###

####

Mobile Phone

Primary contacts mobile phone number.

(###)

###

####

Eligibility Criteria *

Is the participant:

Able and willing to socialize in group settings

Able to toilet independently

Not considered a flight risk

Not aggressive towards themselves or others

LIABILITY WAIVER: I acknowledge that participation in Transition program activities may expose me to the possibility of injury. I grant Hamilton & District Extend-A-Family staff and adult volunteers the authority to obtain emergency medical treatment on my behalf, as necessary to protect myself from further harm or injury. I agree to waive and release Hamilton & District Extend-A-Family from all claims for damages that may arise, other than by negligence of Hamilton & District Extend-A-Family, or its employees, volunteers, and agents, as a result of participation in agency events: *

I have read and agree to the statement.

I hereby give consent to Hamilton & District Extend-A-Family to share my personal information with staff members as it applies to program participation: *

I have read and agree to the statement.

As a condition of the program activities the youth has engaged in, I, for myself, the youth, my executors and assigns, further agree to release and forever discharge Hamilton & District Extend-A-Family, its Board of Directors, officers, employees and volunteers from any claim that I might have myself or that I could bring on the youths behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of the programs and activities that Hamilton & District Extend-A-Family has delivered. *

I have read and agree to the statement.

The Staff and Volunteers of Extend-A-Family are required to sign a confidentiality agreement prior to working with families and will ensure that your privacy is maintained, with the following exceptions: • They are required by law to report any incident of perceived child abuse • They are required by law to report any indication that a person intends to harm themselves or others • Staff and volunteers will respectfully discuss familial information that is relevant to providing the best client centered support possible *

I have read and agree to the statement.

The participant will not be under the influence of recreational drugs and alcohol during the program *

I have read and agree to the statement.

I grant Hamilton & District Extend-A-Family consent to use photographs or video footage taken by agency staff or volunteers to promote our agency via internet, social networking sites, agency newsletters, brochures, and other media: *

Yes

No

I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms. Participants release Hamilton Extend-A-Family, the board, employees and volunteers of all liability regarding 1) any injury to self or others and 2) any loss or damage to personal property.

I have read and agree to this statement.

Name of Parent, Guardian, or Participant. *

First Name

Last Name

Date of Application *

MM

DD

YYYY