Companionship's Club Pierce Registration

2. Companionship's Club Pierce
   For ages 20-30 years.

   For ages 20-30 years.

4. Participant's Name*

6. Age*

7. Date of Birth*
   Date of Birth

8. Gender*

   1. Male

   1. Female

10. Participant's Diagnosis (in laymen's terms please)*

12. Parent/Guardian's Name*

14. Address*

15. City*

16. Zip*

18. Phone*

19. Alternate Phone

21. Email*

23. Emergency Contact Name*

24. Emergency Contact Phone*

28. Wednesdays at Meridian Habitat Park and Community Center (8 am to 3 pm)
    Due to COVID-19 social distancing April dates have been cancelled

    Due to COVID-19 social distancing April dates have been cancelled

30. May 2020

    1. 5/6 ($30)
    2. 5/13 ($25)
    3. 5/20 ($30)
    4. 5/27 ($25)

    Register by April 20

31. June 2020

    1. 6/3 ($25)
    2. 6/10 ($30)
    3. 6/17 ($30)

    Register by May 20

33. Fridays at Lakewood Community Center (8 am to 3 pm)
    Due to COVID-19 social distancing April dates have been cancelled

    Due to COVID-19 social distancing April dates have been cancelled

35. May 2020

    1. 5/1 ($30)
    2. 5/8 ($25)
    3. 5/15 ($30)
    4. 5/29 ($30)

    Register by April 20

36. June 2020

    1. 6/5 ($30)
    2. 6/12 ($25)
    3. 6/19 ($30)

    Register by May 20

40. 1-to-1 assistants
    All staff, volunteers, care providers, and 1-to-1 assistants at Club Pierce are required to have completed, submitted, and approved background checks prior to participating. This process can take up to a week to complete.

    All staff, volunteers, care providers, and 1-to-1 assistants at Club Pierce are required to have completed, submitted, and approved background checks prior to participating. This process can take up to a week to complete.

42. Is a 1-to-1 assistant required?*

    1. Yes
    2. No

43. If yes, assistant name.

44. If yes, assistant phone number.

46. Is the participant taking medicine of any kind?*

    1. Yes
    2. No

47. If yes, please list medicine and time(s) to be taken.

49. Will the participant need to take medications while at Club Pierce?*

    1. Yes
    2. No

50. If yes, please list medicine and time(s) to be taken.

52. Does the participant have allergies?*

    1. Yes
    2. No

    (Food, medicine, etc.)

53. If yes, please list.

55. Are there any special precautions or life-threatening health concerns we should be aware of?*

    1. Yes
    2. No

56. If yes, please explain.

58. Does the participant have blackout spells?*

    1. Yes
    2. No

59. If yes, please explain if necessary.

61. Can the participant dress and change clothes alone?*

    1. Yes
    2. No

62. If no, please explain if necessary.

64. Will the participant take and follow basic instructions or directions?*

    1. Yes
    2. No

65. If no, please explain if necessary.

67. Is the participant able to read independently?*

    1. Yes
    2. No

68. If no, please explain if necessary.

70. Is the participant able to write independently?*

    1. Yes
    2. No

71. If no, please explain if necessary.

73. Can the participant independently ambulate for a distance of at least two city blocks without needing to stop?*

    1. Yes
    2. No

74. If no, please explain if necessary.

76. Does the participant use any special equipment to ambulate?*

    1. Yes
    2. No

    (walker, wheelchair, crutches, etc.)

77. If yes, please explain.

79. Does the participant become overwhelmed in some situations?*

    1. Yes
    2. No

80. If yes, what suggestions and/or strategies help calm them?

82. Bathrooms
    Club Pierce will be out in the community the majority of the time and bathrooms will not always be immediately available.

    Club Pierce will be out in the community the majority of the time and bathrooms will not always be immediately available.

84. Is the participant able to identify and indicate that they need to use the bathroom at least 15 minutes before it becomes an emergency?*

    1. Yes
    2. No

85. If no, please explain if necessary.

87. Will the participant use the bathroom when instructed?*

    1. Yes
    2. No

88. If no, please explain if necessary.

90. Can the participant use the bathroom without assistance?*

    1. Yes
    2. No

91. If no, please explain if necessary.

95. Will the participant use Pierce Shuttle to transport to and/or from Club PIerce?*

    1. Yes
    2. No

99. Is DSHS/DDA providing financial assistance?*

    1. Yes
    2. No

100. If yes, DSHS/DDA manager.

101. If yes, DSHS/DDA phone number.

105. Consent
     I give my consent to Pierce County Parks and Recreation to photograph my child and to use such pictures and/or stories in connection with the program activities. I hereby request that my child be permitted to attend the Club Pierce recreation program for individuals with special needs and authorize the director of the program to act for me according to their best judgement and ability in any emergency requiring medical care.

     I give my consent to Pierce County Parks and Recreation to photograph my child and to use such pictures and/or stories in connection with the program activities. I hereby request that my child be permitted to attend the Club Pierce recreation program for individuals with special needs and authorize the director of the program to act for me according to their best judgement and ability in any emergency requiring medical care.

107. Electronic Signature*

     Please type in your first and last name (Parent or Legal Guardian).

108. Reminder
     Participants should bring a sack lunch each day.

     Participants should bring a sack lunch each day.

112. Pierce County Parks and Recreation staff will contact you for registration confirmation and payment (if paying by credit card or DSHS/DDA funding). If you have not been contacted within two business days, please call (253) 798-4199.

     Pierce County Parks and Recreation staff will contact you for registration confirmation and payment (if paying by credit card or DSHS/DDA funding). If you have not been contacted within two business days, please call (253) 798-4199.

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114. 1. Receive an email copy of this form.
115. Email address

     This field is not part of the form submission.

116. Submit

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