In the Know Registration - Community Living Hamilton

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Participant Name

Phone

D.O.B.

Full Address

Transportation Arrangements

DARTSHSROther

# (if applicable)

Please describe:

Contact Information

Contact Name

Phone

Full Address (if different from above)

Relationship

Billing Name/Address (if different from above)

In the Know & On the Go Selections:

Activity

Start Date

End Date

Fee

Total:

I give permission to Community Living Hamilton to take payment from CLH Administered Passport Funding.
YesNo

Signature

Name

This program is designed for adults 18 years of age and older who can participate independently with a ratio of 1 staff to 6 participants.

For any other questions, please contact:
Suzana Serravalle, Coordinator, Community Resources
Phone: 905-528-0281 x262
Please email forms to: sserravalle@clham.com
Or Mail: 191 York Blvd, Hamilton, ON L8R 1Y6

Please DO NOT send payment with registration form. Invoice will follow.

Medical/Behavioural Information:

Does the client have seizures?
YesNo
If yes, please describe:

Does the client require behavioural re‐direction?
YesNo
If yes, please list strategies that would be helpful:

Is there a Behaviour Support Plan in place? (if yes please attach)
YesNo
Attach Document

We are unable to administer medication or support any medical care needs in these supported leisure programs. Are there any other needs you want us to know about (e.g. asthma, hearing, sight)?

Allergy Information:

Do you have life threatening allergies?
YesNo

Do you carry an Epipen?
YesNo

Identify:

Any other allergies:

Mobility Information:

Mobility/ transfer support?
YesNo
If yes please describe

Support for personal hygiene/ toileting?
YesNo
If yes please explain

Assistance with eating and drinking?
YesNo
If yes please explain

I give permission to Community Living Hamilton to take my photograph for identifications purposes and for any promotional purpose
YesNo

Alternate Contact Information: (Reachable During Activity)

Name

Phone

Relationship

Work/Mobile #

At times our programs may be unable to accommodate every registrant.
We will contact you directly to discuss any questions or concerns.
All activities are held based on the number of registrants. Fees support staffing, transportation and other costs.
We are not able to provide a refund if registered individuals cannot attend any scheduled In The Know or On The go sessions

PAYMENT, CANCELATION, TRANSFER AND REFUNDS

Full payment is due upon registration. Cancelations with less than 30 days’ notice are non-refundable. All efforts will be made to transfer to another activity should there be availability, or the amount can be credited towards a future activity. Cancelations with more than 30 days of the registered activity will be accepted and a full refund will be provided.

Community Living Hamilton reserves the right to alter or modify itineraries as appropriate and alter costs as necessary. Should a change or cancelation occur, we will give you reasonable notice of the change or cancellation and if possible, offer a comparable alternative.

If Community Living Hamilton must cancel a program/ outing for reasons beyond our control, a partial refund less and prepaid expenses will be granted. If the event is cancelled in advance, a full refund will be granted, or the amount credited towards a future activity.

Initial*

DISCLOSURE

The individual and their representative agrees that they have disclosed to Community Living Hamilton every matter relevant to their condition which might impact upon our ability to provide the participant with the appropriate level of care while participating in our service. Failure to disclose relevant information regarding behaviour that is likely to affect the smooth operation of the activity, adversely affect the enjoyment of others, or the safety of themselves and others may result in your removal at any time in any program without reimbursement.

Initial*

SUPPORT LEVELS

To participate in any In the Know / On the Go, or Summer Vibes programs, you must be able to be supported in a one staff to six-person ratio and are reasonably independent in your own care. You also do not require significant intervention or redirection for behaviour

Initial*

CONSENT TO MEDICAL TREATMENT

You or your representative, give permission to Community Living Hamilton to seek medical treatment should an emergency arise. If you require special medical attention, transportation, or treatment beyond that which is possible while participating in our program, the cost for these services will be at your expense.

You or your representative also give permission to Community Living Hamilton to administer prescription medication as prescribed and when required.

Initial*

LIABILITY

While every precaution is taken for the safety and good health of our clients, some activities carry inherent risk of person injury beyond the risks associated with typical recreational programs offered by Community Living Hamilton.

In addition, you are consenting to be transported in a Community Living Hamilton vehicle when required.

By signing below, you acknowledge and accept these risks and agree by participating in these activities, you acknowledge taking part in these activities presents the potential for personal injury. You are releasing Community Living Hamilton’s employees, directors, officers, staff, and volunteers from any and all actions, caused of action, claims and demands resulting from any loss, injury or damage to person, property which has arisen or may arise from any and all programs of Community Living Hamilton, notwithstanding that any such loss, injury or damage may have arisen by reason of negligence of the releases.

Name*

Signature*

Date*