This registration form will provide us with details on how your participant communicates, any triggers/fears/anxieties, supports, rewards, and interests. Please take your time when filling this out and be as detailed as possible so we can get to know your participant and be more prepared to work with them.
Middle School Social Skills Group (Thursdays at 4pm)
High School Social Skills Group (Tuesdays at 4pm)
Detailed information regarding the above diagnosis will hep us work with your particpant more effectively. Explain any health/medical conditions or concerns and any related special instructions.
PARTICIPANT COMMUNICATION SKILLS
Describe your participant's method of communication and understanding:
Please provide any additional information to help us understand how your participant communicates.
PARTICIPANT PROFILE & INTERESTS
List any triggers that may cause participant to become upset or type NONE.
When participant is upset, please describe their typical response and ways to calm them down.
List some of participant's interests / favorite characters / fascinations / fidgets.
List some favorite rewards participant enjoys working for.
REQUIRED POLICIES & AGREEMENTS
Release of Liability I hereby agree/grant permission for my child to take part in this Social Skills program. My child is participating in this Social Skills program upon the express agreement and understanding that I hereby waive and release the Autism Society Greater Akron (ASGA) and its directors, affiliates, partners, officers, agents, contractors, employees, and affiliates from any and all claims, costs, liabilities, expenses, or judgements. This includes attorney fees and court costs (heron collectively "Claims") arising from my child participating in this Social Skills program or any illness or injury resulting from, and hereby agree to indemnify and hold harmless: ASGA and its directors, affiliates, partners, officers, agents, contractors, employees, and affiliates from and against any and all such Claims.
Confidentiality & Information SharingI understand that my child will be engaging in live video conferencing via Zoom with other students. I affirm that my child will conduct the program in privacy, no recordings will be made, and any observation of a session by a parent, guardian or other individual will not be shared with anyone else. I give ASGA permission to share my contact information with other participants in this Social Skills program. This allows participants to keep in touch with each other if they desire to do so during and after the program.
Photo/Video ReleaseI give ASGA permission to publish photographs or video of my child in any promotional material without incurring any liability to ASGA or any photographer/videographer hired on behalf of ASGA. Names will NOT be used with the photographs. The materials may include, but are not limited to, newsletters, annual reports, brochures, advertisements, websites, social media sites, training materials, and/or posters.
DisclaimerSocial Skill Groups offered by the Autism Society of Greater Akron, are intended to foster social skills in a relaxed and supportive atmosphere. They are not intended as therapy or treatment for autism or any mental health or physical disorders. ASGA is not able to provide medical or psychotherapeutic advice, diagnosis, or treatment.
By typing my name in the box below, I confirm that I have read and agree with the above policies and agreements. You will receive a copy of these policies and agreements in the confirmation email.