Email Address of Person Completing Form |
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Group Home
Non-Group Home |
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*Consumers Name: (First, Last)
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*Primary Contact Person
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Secondary Contact Person
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* Address:
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* City:
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* Zip:
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* Home Phone:
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Cell Phone:
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Please note any required
medications and physical disabilities that would require
special attention or consumer needs
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Check Event Requested
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*Event 1:
*Event 2:
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Group Home Information:
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*Primary Contact Person:
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*Secondary Contact Person:
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*Group Home Phone:
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*Cell Phone:
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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:
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*Name Event 1: |
*Name Event 2: |
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Aurora Club Use:
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Security Code |
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Notes:
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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.
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All fees are due prior to the
schedule activity.
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All consumers must be drop off
and picked up at designated time.
Failure to do so may jeopardize future
participation.
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Consumers may not participate
if determined by
Aurora
that the consumer is ill or contagious.
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