Member Information Form

Member Information Form
It is the responsibility of the participant, parent, or legal guardian to keep this information current. This information needs to be completed when you begin your membership and every 3 years when you renew your membership. If this information has not been completed, you will be unable to participate in any activity or event. All information will be kept confidential.

ONE FORM PER PERSON

DO NOT PRINT THIS FORM AND THEN COMPLETE IT.

COMPLETE THIS FORM ONLINE AND WHEN ALL REQUIRED FIELDS ARE COMPLETED, CLICK THE GREEN SUBMIT BUTTON AT THE BOTTOM.
Membership
Membership *

New Renewal
Membership Rates *

Youth (Up to age 17) - FREE Yearly Adult (Ages 18 and Up) - $30.00 Yearly Household * (I am included in my household membership) Already Paid Membership - I am just updating my information, so I can register and attend activities.
Household * Membership Name *
If you are not included in a Household Membership, please type N/A.
Membership Payment *

Cash - Please drop off cash at LIFE Mower County, 401 2nd Ave NE, Austin, MN 55912 Check - Please drop off or mail check to LIFE Mower County, 401 2nd Ave NE, Austin, MN 55912 Credit or Debit Card - Please call or visit the LIFE Mower County office during business hours with your credit or debit card information Already Paid Membership - I am just updating my information, so I can register and attend activities.
Your membership will not be valid until payment has been received.
COVID-19 Vaccine
Have you received a COVID-19 Vaccine? *

Pfizer-BioNTech COVID-19 Vaccine - 1 Dose Pfizer-BioNTech COVID-19 Vaccine - 2 Doses Pfizer-BioNTech COVID-19 Vaccine - 2 Doses + Booster Moderna COVID-19 Vaccine - 1 Dose Moderna COVID-19 Vaccine - 2 Doses Moderna COVID-19 Vaccine - 2 Doses + Booster Janssen COVID-19 Vaccine (Johnson & Johnson) - 1 Dose Janssen COVID-19 Vaccine (Johnson & Johnson) - 1 Dose + Booster None of the above
1st Dose Vaccination Date *

Month Day Year
Date
2nd Dose Vaccination Date *

Month Day Year
Date
Booster Vaccination Date *

Month Day Year
Date
General Information
Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County *
Home Phone Number *
I have a cell phone: *

Yes No
Cell Phone Number *
If you do not have cell phone number, please provide a cell phone number for your parent, guardian or staff.
Primary Email *
example@example.com - If you do not have any email address, please provide an email address for your parent, guardian or staff.
Secondary Email *
example@example.com - If you do not have any email address, please provide an email address for your parent, guardian or staff or put N/A.
Birthday *

Month Day Year
Date
Gender *

Male Female
Hometown *
Employer *
Upload Recent Member Picture Here

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A photo can also be taken at the LIFE Mower County office.
Cancel of
Disability *
Emergency Contact Information
Emergency Contact Name #1 *

First Name Last Name
Emergency Contact Phone #1 *
Emergency Contact Relationship To Member #1 *
Emergency Contact Name #2 *

First Name Last Name
Emergency Contact Phone Number #2 *
Emergency Contact Relationship To Member #2 *
Guardianship Information
I am my own guardian *

Yes No
Guardian Name *

First Name Last Name
Guardian Address *

Street Address

Street Address Line 2

City State

Zip Code
Guardian Phone Number *
Guardian Email *
If no email is available, please type N/A.
Case Manager Information
I have a Case Manager *

Yes No
Case Manager Name *

First Name Last Name
Case Manager Phone Number *
Case Manager Email *
If no email is available, please type N/A.
Demographic Information
Household Income *

$11,490+ $15,510+ $19,530+ $23,550+ $27,570+
Ethinicity *

American Indian or Alaska Native Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other
Living Situation *

Independent Parent's Home Group Home - Please complete information below Foster Home - Please complete information below Semi-Independent - Please complete information below
Residential Provider Name *
Residential Coordinator *

First Name Last Name
Residential Coordinator Phone *
Residential Coordinator Email *
example@example.com
My hobbies and interests are *
Activities that I would like to do with LIFE Mower County *
Times that work best for me to attend activities *

Weekday Mornings Weekday Afternoons Weekday Evenings Weekend Mornings Weekend Afternoons Weekend Evenings
Days that work best for me to attend activities *

Sunday Monday Tuesday Wednesday Thursday Friday Saturday
These things might prevent me from participating in activities at LIFE Mower County *

Financial difficulties Lack of transportation Lack of knowledge of scheduled activities None of the above Other
What do you hope to achieve or experience while you are a member of LIFE Mower County? *
Health Information
Health History *

Allergies Asthma Behavioral Problems Blindness/Visual Problems Bone/Joint Problems Chest Pain Concussion/Head Injury Contact Lenses/Glasses Diabetes Dietary Concerns Hearing Loss/Hearing Aid Heart Disease Heat Stroke High Blood Pressure Immunizations Up To Date Major Surgery Seizures None of the above Other
If you have checked any of the items in the Health History, please explain: *
Physical Limits *

Cane Climb Stairs Wheelchair or Walker Trouble Walking None of the above Other
If you have checked any of the items in the Physical Limits section, please explain *
Self-Administer Medications *

Yes No
Need verbal reminders to take medications *

Yes No
Medication Side Effects *
Life Skills Information
Does the member require 24 hour supervision? *

Yes No
Can the member be left alone? *

Yes No
Amount of time member can be left alone *
Setting in which participant can be left alone *
Member can leave the LIFE Mower County group? *

Yes No
Does the member need to have staff with him/her at LIFE Mower County programs? *

Yes No
Can the member manage his/her own money? *

Yes No
Behavior Information
Behavior Information *

Aggression Attention Seeking Biting Defiance/Refusal Difficult Transitions Easily Distracted Fears/Phobias Hair Pulling Hitting Hyperactivity Inappropriate interactions with others Kicking Manipulative Pinching Removal of Clothing Runs/Wanders Self-Harm/Injury Spitting Stealing Steals Throwing Objects Verbal Outbursts Wanders from Group None of the above Other
If any boxes are checked, please explain. *
If no boxes are checked above, please type N/A
Consent / Permission
Medication Assistance - I give permission to LIFE Mower County to assist the Participant with any prescription or over the counter medication(s) their physician has approved or prescribed: *

Yes No
Photos: I give permission to LIFE Mower County to use my likeness, name, voice, and words in television, radio, film, newspaper, magazines and any other media (www.lifemowercounty.org and www.facebook.com/lifemowercounty) in any form for promotional or educational purposes. *

Yes No
Trips (Community Connections), Vacations: I give permission to the Participant to participate in Trips (Community Connections) and Vacations: *

Yes No
Consent and Release of Liability

I know that participation is a privilege. I know of the risks involved in participation and understand that injury may occur and choose to accept such risks.

I voluntarily accept any and all responsibility for my own safety and welfare while participating in programs at LIFE Mower County, with a full understanding of the risks involved. I release and hold harmless LIFE Mower County and its employees from any and all responsibility for any injury or claim resulting from such participation and agree to take no legal action against LIFE Mower County because of any accident or mishap involving my participation. I further authorize the use or disclosure of my individually identifiable health information should treatment for illness or injury become necessary.

I understand that this authorization is voluntary and that I may revoke it at any time by submitting the revocation in writing to LIFE Mower County.
Member Signature *

Clear
Member Name *
Parent/Guardian/Staff Signature *

Clear
Parent/Guardian/Staff Name *
Please verify that you are human *
Should be Empty:

Member Information Form

Membership

COVID-19 Vaccine

General Information

Emergency Contact Information

Guardianship Information

Case Manager Information

Demographic Information

Health Information

Life Skills Information

Behavior Information

Consent / Permission