Application | Columbia Ability Alliance

Step 1 of 5

This field is for validation purposes and should be left unchanged.

Participant Information

Participant Full Name(Required)

First Last

Age(Required)

Shirt Size(Required)

Birth Date(Required)

MM slash DD slash YYYY

Sex(Required)

Male

Female

Home Address(Required)

Street Address City State

Parent / Guardian Information

Parent / Guardian Name(Required)

First Last

Relationship to Participant(Required)

Phone(Required)

Email(Required)

Emergency Contact Information

Emergency Contact Name(Required)

Relationship(Required)

Phone(Required)

Summer Club Session Selection

Please select which week(s) your club member will attend:(Required)

June 22–26 — Into the Wild

July 20–24 — Artistry Unleashed

August 10–14 — Water Wonders

Participant Support Needs

Does the participant require assistance with any of the following?(Required)

Personal Care

Mobility Support

Communication Support

Behavioral Support

Toileting Assistance

Feeding Assistance

Sensory Support

Other

Please explain if marked.

Please explain any important support needs

Will the participant attend with a personal care provider?(Required)

Yes

Please Provide Caregiver Name

Relationship

Phone Number

Medical Information

Primary Diagnosis (Optional)

Allergies

Special Dietary Needs

Seizure History

Yes

Other

Will the participant need medication during club hours?(Required)

Yes

Participants must be able to self-administer medication. Staff may provide reminders but cannot administer medication.

Medication Name(s)

Instructions

Swimming & Water Activity Permission

The participant may participate in supervised swimming and water activities:

Yes

Additional swimming notes:

Transportation

How will the participant arrive and depart each day?

Parent/Guardian Drop-off & Pick-up

Care Provider Transportation

Transportation Service (Dial-A-Ride, etc.)

Other

Payment Information

Weekly Club Cost:

15 Hours of Respite

$200 Private Pay

I'm a Pasco Resident and interested in scholarship assistance.

Case Manager Name if Using Respite Care Funding

Agency

Phone

Photo & Media Release

I give permission for Columbia Ability Alliance to photograph and/or use images and video of the signed up participant for promotional materials, social media, and marketing purposes.(Required)

Yes

Liability & Participation Agreement

I understand that participation in Nexus Summer Club activities involves inherent risk. I release Columbia Ability Alliance, staff, volunteers, and partner organizations from liability except in cases of negligence. I certify that all information provided is accurate and complete. I understand that Columbia Ability Alliance staff cannot provide 1:1 continuous care unless a caregiver is present. I agree to follow all club policies and procedures.(Required)

I Agree

Signature of Applicant or Parent/Guardian/Provider(Required)

Printed Name of Person Signing(Required)