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Donate

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About Us
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Get Involved
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Registration Formadmin2023-11-21T02:55:00+00:00

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REGISTRATION

Registration

SPRING 2024
SUMMER 2024
FALL 2024

All sections must be completed and/or checked in order to complete your registration. Invoices will be sent each month based on participant's/artist's registration days for the semester.

Name (Participant): *

First

Last

Layout

Date of Birth *

Email *

Exceptional Needs/Diagnosis (Participant) *

Please explain the best way to communicate with our friend *

How can we support our adult when there are changes or challenges? *

Are there any concerns we should know about your adult? *

Please list any special medical needs, dietary requirements, food allergies, or areas the participant is working on. This information will be used to help the Mephibo’s House Team to serve the participant as best as possible. * *

Which Cohort will your Artist/Participant be placed in? *

Select ALL Days the artist/participant will register for the entire semester *

Monday
Tuesday
Wednesday
Thursday
Friday

Parent/Guardian Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Cell Phone # *

Emergency Contacts Names: (First & Last) w/ cell phone # *

Personal Phones *

Personal phones and other technology can be distracting and take away from the participant’s experience at Mephibo’s House. Participants are asked to have cell phones and other technology kept on silent and placed in personal bags- unless medically necessary. All emergency communication should go through Mephibo’s House.

I understand, accept, and agree

General Release *

The participant and parent/guardian further understand and acknowledge that Mercy Road will not allow the participant to participate in such activities without releasing and holding harmless Mercy Road according to the terms of this General Release and Hold Harmless Agreement.

I understand, accept, and agree

Photograph or videoed *

I understand that during the event I/my adult/my ward may be photographed or videoed by Mercy Road, and our program partners. By completing this registration form, I am granting permission for photography or videography for possible use in promotional materials for Mercy Road and the Mephibo’s House program. Photographs and videos may be used in social media venues to promote Mephibo’s House.

I understand, accept, and agree

General Release and Hold Harmless *

General Release and Hold Harmless Agreement: The above entered participant, joined by the above entered parent/legal guardian, desires to participate in various programs, camps, events or activities (hereinafter collectively referred to as an "Activity" or "Activities") operated or sponsored by Mercy Road (hereinafter referred to as the "Mercy Road"). The participant and parent/guardian understand and acknowledge that he or she may incur bodily damage or injury while participating in such Activities.

I understand, accept, and agree

Activities release *

Further, the participant/guardian requests the Mercy Road allow the participant to participate in Activities and in consideration thereof agrees to hereby release and forever discharge the Mercy Road, its officers, board, directors and employees, and agents, and any parties volunteering on behalf of the Mercy Road from all actions, claims, costs, expenses, or damages of any kind growing out of or related to any Activity of Mercy Road in which the participant is involved.

I understand, accept, and agree

injuries and damages *

The participant/guardian further acknowledges that this is a full and complete release for all injuries and damages which the participant may sustain as a result of the participant's involvement in any Mercy Road Activity.

I understand, accept, and agree

permission to participate *

I, the participant/parent/guardian, give my permission for me/my adult/my ward to participate in any or all of the Activities under the direction of Mercy Road, and according to the directions and information contained in this Release Form.

I understand, accept, and agree

authorize treatment *

I, the participant/parent/legal guardian, do hereby authorize the treatment of me/my adult/my ward by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger my/his/her life, cause disfigurement, physical impairment or undue discomfort if delayed, while I/my adult/my ward is participating in the Activity, including transportation to and from the Activity site. This authority is granted only after a reasonable attempt has been made to contact me.

I understand, accept, and agree

restroom assistance *

I/my adult/my ward am/is able to use the restroom without help or assistance, OR will be accompanied by a caregiver.

I understand, accept, and agree

follow directions *

I/my adult/my ward am/is able to demonstrate cooperative behavior and will follow directions from staff and volunteers.

I understand, accept, and agree

aggressive behavior *

A participant exhibiting aggressive behavior will be sent home for the day and a mandatory parent/guardian conference will take place before the participant is allowed to return to the program.

I understand, accept, and agree

Orientation *

I agree to attend the Mephibo’s House Orientation before my adult/ward attends Mephibo’s House and understand that I/my adult will be placed on a Waiting List until the Orientation is complete.

I understand, accept, and agree

Transportation *

I understand that it is the parent/caregiver/ward’s sole responsibility to ensure transportation for drop-off and pick-up to and from Mephibo’s House and is safe and on time.

I understand, accept, and agree

Optional Extended Day Program (EDP) (Monday-Thursday) 2:00pm-3:30pm ($3.50 per day)

EDP is intended to provide time for our participants to engage in select activities of their choice.

My Adult will sign up for the following day(s)

Monday
Tuesday
Wednesday
Thursday

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Signature *

Date *

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