Participant Information Form

Participant 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. 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 Rates*

Youth (Up to age 17) - FREE YearlyAdult (Ages 18 and Up) - $30.00 YearlyI would like to participate as a non-member. Non-Members do not receive discounts on activity fees, receive a first look at the activity guide when it is published via email, bi-monthly newsletter delivered to your house or FREE transportation (for those members 18 and older).
Membership*

NewRenewal - I received an email that I need to pay to renew my membership.Renewal - I received an email that my information needs to be updated.
Renewal Membership

Visit https://schedulesplus.com/lifemc/kiosk/ log-in with your phone and pin number and pay your membership fee. You can also mail or drop off your membership fee payment.
Membership Payment*

Cash - Please drop off cash at LIFE Mower County, 401 2nd Ave NE, Austin, MN 55912.Check - Please drop off or mail the check to LIFE Mower County, 401 2nd Ave NE, Austin, MN 55912.Credit or Debit Card - After completing this form, please contact Jamey at 507-473-4832 to process your card information over the phone.
Your membership will not be valid until payment has been received.
General Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

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

YesNo
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*

MonthDayYear
Date
Gender*

MaleFemale
Hometown*
Employer*
Upload Recent Member Picture Here

A photo can also be taken at the LIFE Mower County office.
Cancelof
Disability*
Have you ever been convicted or charged with a criminal offense other than minor traffic violations?*

YesNo
If yes, please explain. If no, type N/A*
Emergency Contact Information
Emergency Contact Name #1*

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

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

YesNo
Guardian Name*

First NameLast Name
Guardian Address*

Street Address

Street Address Line 2

CityState

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

YesNo
Case Manager Name*

First NameLast 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 NativeBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteOther
Living Situation*

IndependentParent's HomeGroup Home - Please complete information belowFoster Home - Please complete information belowSemi-Independent - Please complete information below
Residential Provider Name*
Residential Coordinator*

First NameLast 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 MorningsWeekday AfternoonsWeekday EveningsWeekend MorningsWeekend AfternoonsWeekend Evenings
Days that work best for me to attend activities*

SundayMondayTuesdayWednesdayThursdayFridaySaturday
These things might prevent me from participating in activities at LIFE Mower County*

Financial difficultiesLack of transportationLack of knowledge of scheduled activitiesNone of the aboveOther
What do you hope to achieve or experience while you are a member of LIFE Mower County?*
Health Information
Health History*

AllergiesAsthmaBehavioral ProblemsBlindness/Visual ProblemsBone/Joint ProblemsChest PainConcussion/Head InjuryContact Lenses/GlassesDiabetesDietary ConcernsHearing Loss/Hearing AidHeart DiseaseHeat StrokeHigh Blood PressureImmunizations Up To DateMajor SurgerySeizuresNone of the aboveOther
If you have checked any of the items in the Health History, please explain:*
Physical Limits*

CaneClimb StairsWheelchair or WalkerTrouble WalkingNone of the aboveOther
If you have checked any of the items in the Physical Limits section, please explain*
Self-Administer Medications*

YesNo
Need verbal reminders to take medications*

YesNo
Medication Side Effects*
Life Skills Information
Does the member require 24 hour supervision?*

YesNo
Can the member be left alone?*

YesNo
Amount of time member can be left alone*
Setting in which participant can be left alone*
Member can leave the LIFE Mower County group?*

YesNo
Does the member need to have staff with him/her at LIFE Mower County programs?*

YesNo
Can the member manage his/her own money?*

YesNo
Behavior Information
Behavior Information*

AggressionAttention SeekingBitingDefiance/RefusalDifficult TransitionsEasily DistractedFears/PhobiasHair PullingHittingHyperactivityInappropriate interactions with othersKickingManipulativePinchingRemoval of ClothingRuns/WandersSelf-Harm/InjurySpittingStealingStealsThrowing ObjectsVerbal OutburstsWanders from GroupNone of the aboveOther
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:*

YesNo
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.*

YesNo
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:

Participant Information Form

Membership

General Information

Emergency Contact Information

Guardianship Information

Case Manager Information

Demographic Information

Health Information

Life Skills Information

Behavior Information

Consent / Permission