Participant's Name
*
First Name
Last Name
Participant's Date of Birth
*
MM
DD
YYYY
Participant's Pronouns or Gender
Your Name
*
The name of the person filling out this form
First Name
Last Name
Your Relationship to Participant
*
Your Email Address
*
Your Phone Number
*
(###)
###
####
Mailing Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please select the class(es) that you wish to register for.
Please note: this does not guarantee registration in your preferred class(es). Registration will be confirmed by AIM staff via email before the session begins.
Please select your second choice class(es) that you wish to enroll in if the above class(es) are full.
Please note: this does not guarantee registration in your preferred class(es). Registration will be confirmed by AIM staff via email before the session begins.
Notes/comments on class selections
Are you planning on using DDA Respite Funds to pay for these classes?
If using DDA funds, please include contact information for your DDA Case Manager below.
Members are encouraged to take class independent of caregivers; if member has a support need that requires a caregiver's presence, please let us know.
What kind of music/musical artist does this group member enjoy? Do they have a favorite song? Other favorite instruments, etc.?
Does this group member use any mobility equipment such as a wheelchair, walker, etc.? If yes, please describe.
How might this group member express their needs? (water, bathroom, rest, etc.)
Is this group member independent in the bathroom? If not, please share what staff needs to know to provide the best support.
Is there anything teachers ought to know about this group member to help keep themselves and others safe while in class?
Does this group member have any medical needs? If yes, please share what staff will need to know to help this group member in class.
Does this group member have any sensitivities? What, if anything, helps?
Please share a bit about this group member's school setting, if applicable.
How does this group member show they are getting dysregulated, overwhelmed, or distressed? What, if anything, helps?
What do you think this group member will enjoy most about class? What might be more challenging?
What do you hope this group member gains from this class experience?
Lastly, please share anything else you would like us to know about this group member that will help us support them for a positive class experience.
Zip Code
Which of the following best represents the group member's race?
Please check all that apply
If Other, please specify
Does the group member identify as Hispanic/Latinx?
What language do you prefer to speak at home?
If Other, please specify
What gender does the group member identify as?
If Self-describes in another way, please specify
