Beyond Programs Registration Health Form 2020

Please register here to participate in any of our Beyond Programs: SNL or Beyond.  You must complete this form to help us provide a safe and fun environment for all who attend.  For any fields that do not pertain, put "N/A".  If you have any questions please contact disabilities@gfc.org. 

 

Thank You.

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code
*Parent/Guardian Names:
*Guardian Cell Phone:
*Guardian Email:
*Emergency Contact if guardians can't be reached:
*Emergency Contact Phone Number:
*Are you your own legal guardian?:
*Gender:
*Where do you live?:
*Birthday:
What do you like to do for fun?:
*What is your job or day program?:
*List all medications currently being taken::
*Please List ALL diagnosed disablities and/or conditions (including mental health and or behavior disorders):
List all allergies including food and medication:
*Please explain any asistance needed at meals including, texture modifications, bite size, special equipment, type of assistance:
Do you need assitance using the bathroom if yes, please explain:
How do you communicate?:
Do you use any adaptive equipment for mobility:
*What type of supervision is reqired during activities?:
Is there a history of agressive or inappropriate behaviors? If yes please explain:
Consent and Liabilities: Please answer yes or no to the following questions/statements. These help protect us, as the respite provider, and you, as the participant.:
*May we take photos with the participant in them?:
Should the above registrant be stricken in any way and in the opinion of the adult in charge, should require emergency treatment, we give permission to seek medical help, including surgery.:
*Medical Intervention:
I will not hold the leaders, staff, members volunteers of Grace Fellowship Church responsible for lost, stolen or damaged property brought to Rest Day by myself or my child.:
*Property Waiver:
I will not hold the leaders or staff of Rest Day at Grace Fellowship Church responsible in any way in the event of an accident.:
*Accident Waiver:

9505 Deereco Road
Timonium, MD 21093
410.561.8424 | info@gfc.org

Saturday - 5:00pm
Sunday - 9:30am & 11:00am