DAC Client Intake and Participant Agreement

DAC Client Intake and Participation Agreement

First Name:	* Required
Last Name:	* Required
Social Security #:	* Required
Birthdate:	* Required
Address:	* Required
City:	* Required
State:	* Required
Zip:	* Required
Home Phone:	* Required
Cell Phone:	* Required
Email:	* Required
School & Teacher	* Required
Grade:	* Required
Do you have an IEP?
504 Plan?
Race:	* Required
Hispanic or Latino:
Do you have a disability, if yes, Please explain:
Will you need special accomodations to participate in our program?
Are you receiving Social Security (SSI / SSDI)? If Yes, Amount:
Are you currrently working with any other agencies? If Yes, please name:
What services or programs are you looking for from the Disability Action Center?
Emergency Contact Name, Relationship, Home Phone Number, Cell	* Required
Is the above the Legal Guardianship?
Alternate Contact Name, Relationship, Home Phone Number, Cell Phone:	* Required
Do you have special medication conditions or are you taking medication the DAC should know about? Please Explain:
1) Employer, Supervisor Name, Address, Phone Number, Date of Employment (Start Date / End Date), Hours Worked Per Week, Reason for Leaving, and Job Duties.
2) Employer, Supervisor Name, Address, Phone Number, Date of Employment (Start Date / End Date), Hours Worked Per Week, Reason for Leaving, and Job Duties.
Participant Agreement By participating in programs of the Disability Action Center, I understand that information gathered and shared with staff, volunteers, and Board members is kept confidential unless deemed a safety issue to myself or others unless I give my consent to share the information via the Consent for Release of Information. I understand that my participation in Disability Action Center activities and programs is voluntary and there is no penalty or consequence for discontinuing participation at any time during the programs. I understand that the Disability Action Center will not be responsible for injury, accident, loss or damage of property, or other liabilities that are of no direct responsibility of the center, our staff, volunteers, or Board members. I understand that by participating in programs and activities of the Disability Action Center I may travel in vehicles with DAC staff, volunteers, or Board members, and the aforementioned are not responsible for injury, damage to property, or accident that occurs while providing me transportation. I understand that the Disability Action Center documents the programs and activities in a photographic and media archive wherein my photograph may be used in brochures, websites, social networking sites, promotional materials, and other print materials. I understand that I must adhere to the Disability Action Center Code of Conduct while participating in DAC activities and programs.
Participation Agreement	* Required

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