Social Skills Class Enrollment Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Class Start Date *Enter the start date for the Class.Class Start Time *Enter the starting time for the Class. Is attending Other Participant's Name *FirstLastParticipant's Preferred Name/Nickname *Date of Birth *Phone Number *Email Address *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code Emergency Contact Emergency Contact's Name *FirstLastRelationship *Phone Number * Disability Information (Confidential) Primary Disability/Diagnosis *Communication Needs (e.g. AAC device, interpreter, slow processing)Sensory Sensitivities or Triggers (e.g. noise, touch, lights)Behavioral Support Needs (e.g. anxiety, outbursts)Mobility Considerations (e.g. wheelchair, walker, assistance)Is a support person attending with the participant? *YesNoSupport Person's Name *FirstLastSupport Person's Role *Group Goals What would you like to get out of this class? (Select all that apply) *Making FriendsLearning Conversational SkillsPracticing Appropriate Social BehaviorLearning to Manage Social AnxietyImproving RelationshipsOther:Other Description *Participant Agreement By signing below, I acknowledge and agree to the following: Voluntary Participation: I understand participation in the Social Skills Class is voluntary and designed for persons with disabilities to practice social interaction, communication, and group skills in a safe and supportive environment. Respectful Behavior: I agree to participate in a respectful and appropriate manner. I understand that repeated unsafe, aggressive, or disruptive behavior may result in temporary or permanent dismissal from the class. Medical Clearance: I affirm that I am physically and emotionally able to participate in a group setting, or have been cleared by a medical or mental health professional. Confidentiality: I understand that class conversations are private, and I agree not to share personal details of other participants outside of the class setting. Release of Liability In consideration of participation in the social skills class facilitated by Building Bridges Through Communication, I, the undersigned, agree to the following: I release and hold harmless Building Bridges Through Communication, its staff, volunteers, and affiliates from any and all liability, claims, demands, damages, or causes of action that may arise from my participation in the class. This includes, but is not limited to, injury, emotional distress, or other harm, whether caused by negligence or otherwise. I understand that the class is not a form of therapy or clinical counseling and does not replace professional mental health care. Photo/Video Release (Optional) Do you grant permission to Building Bridges Through Communication for using the photographs or video recordings taken of you during class for promotional, educational, and/or informational purposes? Checkboxes *I grant BBTC permission to use my photographs and/or video recordingsI DO NOT grant BBTC permission to use my photographs or videosConsent I have read this waiver and release of liability form, fully understand its terms, and sign it freely and voluntarily. Consent *I am the participant and I am legally competent to sign this releaseI am the parent/legal guardian of the participant and am authorized to sign on their behalfType Participant / Guardian Name to Sign *Date Signed"Legal" Consent *I understand that typing my name here constitutes a legal electronic signature.Submit
