All Stars for Autism New Membership Form This form is required for all families joining All Stars for Autism’s social programs Child 1 * First Name Last Name Child 1 Date of Birth * Additional Child If applicable First Name Last Name Child Date of Birth Additional Child If applicable First Name Last Name Child Date of Birth Parent/Carer Name * First Name Last Name Contact Phone Number * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Emergency Contact * First Name Last Name Emergency Contact Phone Number * Is your child able to follow verbal instructions? If not, how can we best encourage participation? * Is your child able to regulate their emotions and work cooperatively with others in a group dynamic? If not, how can we help best support your child? * Does your child behave in a safe manner towards others in a group setting? * Yes No Unsure What are some of your child's interests, talents or skills they may like to explore and expand upon in the sessions? * Does your child have any additional medical conditions we need to be aware of? If yes, please provide details. * Does your child have any allergies or dietary requirements? * Consent to use photographs and images (optional) You agree that All Stars for Autism Incorporated may take photographs and video footage of you/your child/your children undertaking activities and use it for the purposes of marketing and promotion of All Stars for Autism Incorporated and its goods or services. This may include printed and digital marketing, including the use of you/your child/your children image on social media platforms. Yes No Exclusion of Liability * This agreement releases All Stars for Autism Inc. from all liability relating to injuries that may occur during All Stars for Autism’s events. By signing this agreement, I agree to absolve All Stars for Autism Inc. from all liability however arising, from injury or damage however caused, arising out of mine or my child’s membership and/or participation in any All Stars for Autism activity. Yes No Kindness Promise Policy * The 'Kindness Promise’, has been co-designed with some of our autistic participants and incorporates their vision for inclusion and fairness in our community. We ask for your support in making sure each child understands the expectations of this promise, to the best of their ability, which applies across all groups and will be reinforced consistently by our staff. We want All Stars to continue to be a safe, welcoming and inclusive space for all children. Please be aware that if your child is consistently unable to keep the ‘Kindness Promise’ we will need to reassess their enrolment in the program. I agree to discuss the Kindness Promise with my child before attending an All Stars for Autism program. Yes No Privacy Policy * I agree to the All Stars for Autism Privacy Policy. Yes No Program you are enrolling in * All Stars Kids Club All Stars Juniors All Stars Art Connect School Holiday Events Telethon Teen Mentoring Program Gaming Gang All Stars Ten Pin Bowling League Full Name * By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form. Date MM DD YYYY Thank you for completing the All Stars for Autism New Membership Form. We look forward to seeing you soon.
