Spring Social Skills Registration

Participant's Name*

First Last

Participant's Date of Birth*

Participant's Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Name*

First Last

Parent/Guardian Address is the same as Participant's.

Yes

Parent/Guardian Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian E-mail*

Parent/Guardian Phone*

County*

Will the participant be attending with a Direct Support Professional?*

Yes
No

Please select your membership status.*

AuSM Member or Renewing Today
Non-Member

If you are uncertain of your membership status, please email Maura at mmcdonald@ausm.org for confirmation.

Select the classes for which you are registering.*

Self-Advocacy in Action- $150

Select the classes for which you are registering.*

Comedy Sportz Improv Skills Advanced- $325
Self-Advocacy In Action- $150

Total

$0.00

Emergency Contact and Medical Information

Emergency Contact is Parent/Guardian

Yes

Emergency Contact Name*

First Last

Emergency Contact E-mail*

Emergency Contact Phone*

If participant has food, nut, insect, animal, or drug allergies, please list those here. If this is not applicable to participant, please type "none".*

If participant has life-threatening issues that may occur during this program (e.g. seizures, diabetes, asthma), please list those here. If this is not applicable to participant, please type "none".*

If participant carries fast-acting medications (epi-pen, asthma inhaler, etc.), please list those here and note their purpose. If this is not applicable to participant, please type "none".*

Photo/Video Release and Information Sharing

I hereby consent that the Autism Society of Minnesota (AuSM) may videotape, interview, film, or photograph the AuSM Social Skills class participant to illustrate the activities of AuSM. I also grant AuSM or its designee permission to use and/or publish said video, interview, film, or photograph and further waive any right I may have to inspect and/or approve the finished product prior to publication. The materials may include, but are not limited to, newsletters, annual reports, brochures, advertisements, websites, social media sites, training materials, and/or posters. Further, I agree that I shall receive no compensation of any kind for the use of my words or likeness. I discharge AuSM from any and all claims which may arise from use of any video, interview, film, and/or photograph.

Check box for photo/video release permission.

I give the Autism Society of Minnesota (AuSM) permission to share my contact information with other participants in this AuSM Social Skills class. This allows students to keep in touch with each other if they desire to do so during and after the class.

Check box for contact information sharing permission.

My AuSM Profile

Please complete this information about the class participant.

Diagnosis/diagnoses*

Triggers*

When I am upset, my typical response is:*

What is the best way to calm me down if I am upset?*

I may need extra help with:*

What do you hope to gain from this class?*

How did you hear about AuSM Social Skills?*

Release of Liability

I hereby agree/grant permission for the participant to take part in all AuSM Social Skills activities. I am/the participant is participating in AuSM Social Skills upon the express agreement and understanding that I hereby waive and release the Autism Society of Minnesota and each of its Social Skills locations and each entity's staff, directors, affiliates, partners, officers, agents, contractors, employees, and each entity's affiliates from any and all claims, costs, liabilities, expenses, or judgements. This includes attorney fees and court costs (heron collectively "Claims") arising from my participating in/the participant participating in AuSM Social Skills or any illness or injury resulting from, and hereby agree to indemnify and hold harmless: the Autism Society of Minnesota and each of its Social Skills locations and each entity's direct and indirect parents and subsidiaries, any of their affiliated entities, successors, and current or future director, officer, employee, partner, member, or agent of any of them from and against any and all such Claims.*

Check box for release of liability.

AuSM Participant Safety Plan During COVID-19 Pandemic

Per state of Minnesota, Centers for Disease Control, and local municipality regulations, AuSM has developed plans and activities that allow for proper health practices while still engaging with one another and having fun. Below is a list of requirements designed for the safety of participants and staff:

In alignment with the State of Minnesota guidelines, AuSM is not requiring participants to wear a mask or face covering while outdoors. With this said, AuSM is adhering to the rules set forth by all locations our program visits.
AuSM encourages participants to bring a mask or face covering that is conducive to their preferences in the event our community partners require participants to wear a mask or face covering while visiting their site. AuSM will provide one disposable mask per participant as needed per session.
Participants and staff will be asked to maintain a safe distance (6 feet) between one another as much as possible. AuSM will have visual tools and structured schedules present to assist participants in following these safety guidelines.
AuSM will supply the following safety-focused sanitary products at each session: hand sanitizer, sanitizer wipes, non-latex gloves.

If participants have challenges complying with these requirements, AuSM is committed to working diligently to find a solution. Staff will work directly with any individuals experiencing difficulties adhering to the safety guidelines. While each situation will be navigated on an individual basis, these are some of the options that will be used:

AuSM developed a social narrative to provide participants with a description of the requirements and a rationale for why they are needed.
Maximization of the use of outdoor space.
Staff will model safe/expected behaviors.
Staff will review requirements with participants and/or families to promote adherence and to collaborate in problem-solving such as:
- Alternative PPE
- Developing visual supports
- Scheduled breaks to remove PPE
If available options have been exhausted, and on-going challenges persist that are not conducive to the health and safety of participants and staff, AuSM reserves the right to have participants end a program early and receive a prorated refund.

As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus,” at any time or in any place, including through participation in this Autism Society of Minnesota program. The Autism Society of Minnesota follows state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases and will continue to do so.

Despite our careful attention to social distancing, disinfecting, hand washing, and requiring participants be healthy when attending classes or activities (absence of fever, chills, sore throat, etc.), there is still a chance that the participant could be exposed to an illness, including COVID-19, during this program.

I have reviewed AuSM’s safety plan and acknowledge that the signature of this waiver as a program participant or as the parent/guardian of a program participant is a prerequisite to participating in the activity, but that it is my choice, made freely and voluntarily, to indicate my agreement online/sign this legally binding document. Although exposure to illness, including COVID-19, is unlikely, do you accept the risk and consent to participate in this Autism Society of Minnesota program?*

Yes
No

Demographic Information

Please specify participant's ethnicity.*

African-American
Asian/Pacific Islander
Caucasian
Hispanic or Latino
Hmong
Native American or American Indian
Somali
Other
Prefer not to answer

If other, please specify.

Please specify participant's gender.*

Female
Male
Other
Prefer not to answer

If other, please specify.

Select your household annual income.*

Less than $10,000
$10,000-$30,000
$30,000-$50,000
$50,000-$70,000
$70,000-$90,000
$90,000-$120,000
$120,000-$150,000
$150,000+
Prefer not to answer

Membership Status

I am joining AuSM or renewing my AuSM membership today.*

Yes
No

Joining AuSM today: which category best describes you?

New Member
Renewing Member

Select your membership category.*

Individual with ASD, 21 years old+ ($20)
Household ($60)

Household Members

Please share some information about the other members of your household. If you have more than 6 members in your household, please call or e-mail 651.647.1083 or membership@ausm.org to provide information about all members of your household.

Please select number of members in your household membership, including the parent/guardian listed on this form, and the participant listed on this form.

Name of third member in household

First Last

Contact info for third member in household is the same as parent/guardian.

Yes

Address of third member in household.

Street Address Address Line 2 City State ZIP Code

E-mail of third member in household.

Date of birth of third member in household.

Name of fourth member in household

First Last

Contact info for fourth member in household is the same as parent/guardian.

Yes

Address of fourth member in household.

Street Address Address Line 2 City State ZIP Code

E-mail of fourth member in household.

Date of birth of fourth member in household.

Name of fifth member in household

First Last

Contact info for fifth member in household is the same as parent/guardian.

Yes

Address of fifth member in household.

Street Address Address Line 2 City State ZIP Code

E-mail of fifth member in household.

Date of birth of fifth member in household.

Name of sixth member in household

First Last

Contact info for sixth member in household is the same as parent/guardian.

Yes

Address of sixth member in household.

Street Address Address Line 2 City State ZIP Code

E-mail of sixth member in household.

Date of birth of sixth member in household.

Payment

Please check with your county case manager to learn if your select class can be paid for under the Community Access for Disability Inclusion (CADI); Brain Injury (BI); Community Alternative Care (CAC); Consumer Support Grant (CSG); Family Support Grant (FSG); or Developmental Disability (DD) waivers. By registering for an AuSM class, you agree to pay in full any amount not covered by the third party payer.

Total

$0.00

I would like to apply for a scholarship.*

Yes
No

How would you like to pay?*

Pay now by credit card
Third party payer

Billing address is the same as mailing address

Yes

Billing Address*

Street Address Address Line 2 City State ZIP Code

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Third Party Payer Organization*

Contact at Third Party Payer*

First Last

Third Party Payer Phone*

Third Party Payer Address*

Street Address Address Line 2 City State ZIP Code

Third Party Payer E-mail*

Scholarship Application

The following questions will help AuSM determine if you are eligible for a scholarship for this event. The information you provide informs this decision. You will be contacted by an AuSM staff member once we receive your application to let you know if your application has been approved and how to proceed.

AuSM aims to make its programs accessible to underserved groups. In order to help us meet this goal, please share the groups to which you identify (as you are comfortable).

I am an autistic adult.
I am part of a racial minority.
I am part of an ethnic minority.
I am LGBTQIA.
I have a disability other than autism.
I live in a rural area.
Other

If other, please specify.

How many people, including yourself, live in your household?*

If you have a circumstance you would like AuSM to take into account in this scholarship consideration, please explain below.

Have you received financial assistance to participate in AuSM programs this year?*

Yes, an AuSM scholarship
Yes, third-party assistance
No

AuSM Social Skills 2022 Spring

Emergency Contact and Medical Information

Photo/Video Release and Information Sharing

My AuSM Profile

Release of Liability

AuSM Participant Safety Plan During COVID-19 Pandemic

Demographic Information

Membership Status

Household Members

Payment

Scholarship Application

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