Aurora

Aurora Social Rehabilitation Services
IDD Activity Registration Form

Email Address of Person Completing Form
	Group Home Non-Group Home
Non - Group Home
*Consumers Name: (First, Last)
*Primary Contact Person
Secondary Contact Person
* Address:
* City:
* Zip:
* Home Phone:
Cell Phone:


Please note any required medications and physical disabilities that would require special attention or consumer needs

Check Event Requested
Event 1: Event 2:

Group Home Information:
*Primary Contact Person:
*Secondary Contact Person:
*Group Home Phone:
*Cell Phone:
Group Home (List name/s of all consumers and note any special needs as described in number 9 who are requesting to attending Event 1 and or Event 2:
*Name Event 1:	*Name Event 2:


Aurora Club Use:

Security Code
Notes: • So that each consumer will have equal access to all activities, Aurora will determine each consumer’s participation based the consumer’s ability to fully participate. Aurora will also consider, the consumer to staff ratio (5-1), transportation and frequency of participation. • All fees are due prior to the schedule activity. • All consumers must be drop off and picked up at designated time. Failure to do so may jeopardize future participation. • Consumers may not participate if determined by Aurora that the consumer is ill or contagious.