Art Academy For Autism for Adults Application

Art Academy for Autism for Adults Application

* Indicates required field

Student's Name *

First

Last

Parent/Caretaker's Name *

First

Last

Student's Age *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

How Did You Hear About Our Program? *

Please List Any Known Allergies/Other Conditions Needing Special Attention. *

Are You A Member? *

Yes No

Medical Information

Does the Student Have Any Allergies? If Yes, Please Explain. *

Does the Student Have Seizures? If Yes, Please Explain. *

Does the Student Have Any Food Restrictions? If Yes, Please Explain. *

Does the Student Take Any Medications That Would Prevent Him/Her From Participating In Any Art Academy for Autism Activities? If Yes, Please Explain. *

Any Other Medical Information That You Feel Should Be Disclosed? *

Social Information

What are the student's favorite activities or hobbies? *

What frightens or upsets the student? *

What does the student do to self-sooth/comfort himself/herself? *

List places familiar to the student *

Additional information about the student. *

Please disclose any relevant behavioral information. *

These records will be kept confidential. The information needed here is to create the best program possible for your student. Applying does not guarantee entry to the program. Classes will be assembled based on each student's age and ability. This program is specifically designed and only available for adults with autism or other related disabilities.

Informed Consent and Acknowledgement

In case of accident or serious illness, I request that I/we be contacted. I hereby give permission for emergency medical treatment, which may include, but may not be limited to, initial diagnostic x-rays and other such procedures as the physician may deem necessary for the preservation of health.

Periodically, the PMA takes photographs of educational classes for marketing, promotional materials, or other Museum publications.

By selecting the "Submit" button, I am signing the above informed consent and acknowledgment agreement electronically. I agree that my electronic signature is the legal equivalent of my manual signature on this agreement. By selecting "Submit" I consent to be legally bound by this agreement's terms and conditions. I also understand that registration does not guarantee entry to this class.

Submit