EmailMe Form - Autism Ministry"Seensory & Me" Student Profile

STATEMENT OF CONFIDENTIALITY

All information gathered in this profile will be used by the ministry leaders and partners to accurately assess the needs of your child/children and will be kept strictly confidential.

Student's Name *

First Last

Date of Birth *

Grade Level *

Parent/Guardian's Name *

First Last

Primary Phone# *

### - ### - ####

Additional Parent/Guardian's Name

First Last

Primary Phone#

### - ### - ####

Primary Email *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Student's Diagnosis (if applicable)

Please list allergies below. (if applicable)

Please list preferred snacks below.

Can your child toilet independently? *

Yes

No

If you answered 'yes', if they are non-verbal, how will they communicate they need to go?

Please select the activities below that your child would enjoy participating in: *

Please check all that apply:

1. Has difficulty with transitions/new situations

2. Hurts self

3. Does your child exhibit behaviors such as biting, hitting, kicking, or property destruction?

4. Runner

5. Needs help with feelings

6. Has seizures

Please list any additional information regarding the checked areas above if applicable.

I, my minor child, or a minor child under my legal guardianship (individually and collectively referred to as Participants), intend to participate in the following activity as a student attendee (“Activity”) of the Seensory & Me Special Needs Ministry. *

Select the appropriate selection to indicate your understanding of each paragraph below:

Assumption of Risk. Participants assume all responsibility for Participants’ own safety while participating in the Activity and assert that they are in good health and physical condition. Participants understand that the Activity may be physically demanding and may require physical exertion by Participants. Participants agree to immediately notify WORIC and withdraw from the Activity if their health or physical condition changes. Participants further understand that participation in the Activity is completely voluntary, and Participants assume the risk of any and all injuries that may occur to Participants as a result of participation in the Activity.

Select the appropriate selection to indicate your understanding of each paragraph below:

Waiver and Release. Participants release and forever discharge and hold harmless Word of Restoration International Church, Inc. and its directors, officers, employees, agents, attorneys, related entities, successors, and assigns (collectively, WORIC) from any and all liability, claims, and demands of any kind or nature, either in law or in equity, which exist now or in the future in connection with Participants’ participation in the Activity. Participants understand and agree that this Release discharges WORIC from any liability or claim that Participants may have against WORIC with respect to bodily injury, personal injury, illness, death, property damage, or any other harm that may result from Participants’ participation in the Activity. Participants expressly waive any right to a trial by judge or jury that Participants may otherwise have with regard to any claim or liability related to Participants’ participation in the Activity. *

Select the appropriate selection to indicate your understanding of each paragraph below:

Medical Treatment. Participants consent to receive emergency medical treatment in the event of illness or injury and release and forever discharge WORIC from any liability or claim whatsoever which arises or may later arise on account of any medical services rendered in connection with an emergency during Participants’ participation in the Activity. *

CONSENT

By submitting this form, you agree to be contacted by a representative of Word of Restoration International Church. We respect your privacy. Your information will be used for ministry purposes ONLY.

Select the appropriate selection to indicate your understanding of each paragraph below:

Photo and Media Release. Participants grant to WORIC all right, title, and interest in any and all photographs, images, video, or audio recordings of Participants or Participants’ likeness or voice made by WORIC in connection with the Activity. Participants understand and agree that they will not receive compensation for any use of such material. *

Select the appropriate selection to indicate your understanding of each paragraph below:

Broad Release Intended. Participants expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Texas and that this Release shall be governed by and interpreted in accordance with the laws of the State of Texas. Participants further agree that in the event any clause or provision of this Release is deemed invalid, the enforce-ability of the remaining provisions of this Release shall not be affected. *

Parent/Guardian's Signature *

Clear