Make a payment Elevate - Club Application Step 1 of 3 33% Name:(Required) First Last Address:(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone:(Required)Email:(Required) Date of birth:(Required) MM slash DD slash YYYY Age:(Required) Diagnosis:(Required) Parent/Guardian name(s):(Required) First Last Relationship to Participant:(Required) Guardian's phone:(Required)Email:(Required) EducationDid you graduate from high school?(Required) Yes No If no, would you like to work towards your GED? Yes No Diploma Type: Do you have any living skills training?(Required) Yes No If yes, list any living skills you know: Participant QuestionnaireFor fun, I like to:(Required) I am good at:(Required) I would like to be more independent.(Required) Yes No Home Responsibilities:(Required) I wish I were better at:(Required) I would like a job one day.(Required) Yes No Making friends is a challenge for me.(Required) Yes No AbilitiesI am able to do these things on my own currently:Brush my teeth Yes No Pick out my own clothes Yes No Prepare my lunch Yes No Do My Laundry Yes No Order my food at a restaurant Yes No Start a conversation Yes No Study my bible Yes No Do the dishes Yes No Clean the kitchen Yes No Ask and answer questions Yes No Emergency Information SheetDate(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Participant Name:(Required) First Last Emergency Contact 1:(Required) First Last Phone(Required)Relationship to participant(Required) Emergency Contact 2:(Required) First Last Phone(Required)Relationship to participant(Required) Emergency Contact 3: First Last PhoneRelationship to participant Allergies/ dietary restrictions(Required) Participants Insurance Carrier(Required) ID#(Required) Group#(Required) Primary physician(Required) First Last Phone(Required)In case 911 needs to be called, what is your preferred hospital?(Required) Medication Name/dose:(Required) Time taken(Required) Medication Name/dose: Time taken Medication Name/dose: Time taken Medication Name/dose: Time taken Medication Name/dose: Time taken Do you have difficulty managing your behavior?(Required) Yes No What are some things that make it harder? (triggers)(Required) Do you have a behavior therapist?(Required) Yes No Disclaimer & Signature(Required) I certify that my answers are true and complete to the best of my knowledge.By signing below, I understand that if my child is absent for any reason, no fees will be reimbursed or be transferred to pay for additional weeks. This includes closure for natural disasters or virus-related reasons. I also understand that my child cannot attend If he/she has a fever, vomiting, sore throat, or diarrhea. PARTICIPANT RELEASE, CONSTENT AND LIABILITY WAIVER FORM(Required) The Undersigned, in consideration of being allowed to participate in any way in the LIFT DISABILITY NETWORK, and related events and activities, I for myself, my executors, administrators, heirs, next of kin, successors, and assigns:WAVIER AND RELEASE: I hereby agree to be bound by and comply with all program, federal, and state rules and regulations. I expressly assume all risk(s) associated with each event activity and I hereby release LIFT DISABILITY NETWORK, involved organizations, all sponsors, and volunteers, staff and officials, including, but not limited to each of their respective employees, officers, directors, managers, members, insurers and representatives (collectively “Releasees”) from all claims or injury and/or damage arising out of, or related to and/or incurred in connection with any LIFT DISABILITY NETWORK event(s). I hereby agree to indemnify, defend, and hold harmless Releasees from and against any and all demands, claims, causes of action, (including, but not limited to, causes of action in contract, tort, strict liability or otherwise, and specifically including, but not limited to, any claim of negligence and/or fault of any Releasee), fines, penalties, damages, liabilities, judgments, and expenses (including, without limitation, reasonable attorneys’ fees) incurred in connection with or arising out of my participation and my family’s participation in any LIFT DISABILITY NETWORK program. PHOTO RELEASE: I hereby grant LIFT DISABILITY NETWORK, the unconditional, royalty free, perpetual, right and license to use my name, voice, and photographic likeness in connection with LIFT DISABILITY NETWORK promotions, television shows, and/or articles and press releases. I agree that I am not entitled to receive any royalties or other compensation in connection with such use. INSURANCE, MEDICAL AND ASSUMPTION OF RISK: I further understand and agree that the Elevate Lead reserves the right to deny my entry for any reason. By signing this application I agree that I have sufficient health, accident, and liability insurance to cover any bodily injury or property damage incurred by myself or others as a result of my participation in any LIFT DISABILITY NETWORK event. If I have no such insurance, I declare that I am capable of paying for any and all such expenses or liability. I understand that I am responsible for paying all local, state, and federal taxes, title, license and registration as a result of my participation in any LIFT DISABILITY NETWORK event. I agree that sole and exclusive venue for the determination of any claim or controversy arising out of or related to any LIFT DISABILITY NETWORK events shall be in State District Court, Orange County, FL, where the principal office of LIFT DISABILITY NETWORK is located. Should it become necessary for LIFT DISABILITY NETWORK or any Releasee to incur attorney’s fees and costs to enforce this Release, I agree to pay the attorneys fees thereby LIFT DISABLILITY NETWORK | 611 BUSINESS PARK BLVD., SUITE 105, WINTER GARDEN, FL 34787 | LIFTDISABILITY.NET expended, or for which liability is incurred. If this is a family event, I agree that my family, if absent from signing this Release, understand(s) all statements, rules, and regulations stated above and has given me express permission to sign on their behalf. By signing this Release, I am stating that my family and I both agree to these terms. (A) Waive and release any and all claims that I, or minors under my care, may have against LIFT DISABILITY NETWORK, involved organizations, all sponsors, and event volunteers, staff and officials, including, but not limited to each of their respective employees, officers, directors, managers, members, insurers and representatives or any one or more of them or their executors, administrators, heirs, next of kin, successors, or assigns (the Releasees), including any and all claims for damage caused by the negligence of any of them, arising out of my participation and their related activities, together with any costs, including attorneys' fees that may be incurred as a result of any such claim whether valid or not, and (B) Indemnify and hold harmless the Releasees and each of them against any such claim that I or my guests or any one or more of them or my or their executors, administrators, heirs, next of kin, successors, or assigns may have or assert and against any cost including attorneys' fees with respect thereto. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOUNTARILY WITHOUT AND INDUCEMENT FOR MYSELF AND MINOR CHILDREN UNDER MY CARE.Consent I agree to the privacy policy.(C) Consent: I authorize LIFT DISABILITY NETWORK to obtain and release confidential information about Participant regarding Behavior Intervention Plan, Diagnosis, Assessments, and all Evaluations from School and/or Therapists listed below.School Therapist Parent/Guardian Signature(Required) First Middle Last Type full name for signatureDate(Required) MM slash DD slash YYYY CAPTCHA Δ
