Scarborough Chapter
Participant Registration
Please complete the form below to register for Autism Teenage Partnership
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Please enter the full name of the participant. *

Please enter the name of the participant who will be taking part in Autism Teenage Partnership.
 
Please enter {{answer_5773753}}'s birth date.

 
Day *

 
Year *

 
Please enter the following information about {{answer_5773753}}.

 
Age *

 
Address *

To give us an idea of where you're coming from!

Street Name/Number, City, Province, Postal Code
 
Phone Number *

xxx-xxx-xxxx
 
Photo/Video Release Form *

I hereby give permission for images of {{answer_5773753}} captured during regular and special activities through video, camera, or photography, to be used solely for the purposes of Autism Teenage Partnership and waive any rights of compensation or ownership thereto.

These will be used for things such as our Facebook page, blog, website, and monthly newsletter.

*We are not responsible for any photos/video captured by participants.
     
 
Authorization to Share Information *

We sometimes need to share information about our participants within our organization and partnerships to help us determine support needs, and come up with the best strategies and programs for our participants. This allows us to tap into our partners resources to create the most beneficial programming possible. Information will NOT be shared outside of our organizational partnerships or to third parties. 

I hereby authorize Autism Teenage Partnership to share information about {{answer_5773753}} for the purposes of program planning, determining support needs, and program operations within Autism Teenage Partnership and its partners. 

Autism Teenage Partnership will always act so as to protect your privacy, even with consent to share your information.
     
 
Family/Emergency Contact #1

This information will be used as the main contact information for {{answer_5773753}} should there be any issues.
 
Full Name *

 
Relationship to {{answer_5773753}} *

 
Home Phone Number *

xxx-xxx-xxxx
 
Cell Phone Number

xxx-xxx-xxxx
 
Family/Emergency Contact #2

In case there is an emergency and we are unable to contact anyone at the numbers listed above, please provide the name and numbers of an alternate emergency contact.
 
Full Name *

 
Relationship to {{answer_5773753}} *

 
Home Phone Number *

xxx-xxx-xxxx
 
Cell Phone Number

xxx-xxx-xxxx
 
The following questions will help us to get to know {{answer_5773753}} a little better so we can better suit their needs.

 
Does {{answer_5773753}} have any allergies? If so, please list below.

 
Describe the day-to-day behaviour of {{answer_5773753}}.

 
Is there any form of inappropriate behaviour or aggression? What are the triggers of these behaviours? How do you handle these triggers? Any strategies you may share with us?

 
What are some of {{answer_5773753}}'s hobbies or interests?

 
Describe {{answer_5773753}}'s communication skills. Do they require equipment, actions, signs, etc.? Do they get easily distracted, wander into space, or lose focus easily during interactions?

 
Please tell us your expectations for this program.

 
Is there any other important information you think we should know?

 
By submitting this form, you agree that the information which it contains is accurate and complete to the best of your knowledge.

Any questions or issues will be addressed in person at your first session, or you can reach us through email at info@autismteenagepartnership.org 

By submitting this form, you will also receive our Chapter newsletter to receive programming updates and schedules, which you may opt out of at any point.  

Please note that signatures will be required to verify information at your first ATP session.
Thank you for signing up!
We look forward to meeting you soon!
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