Register

Superhero registration form

There is no cost to visit the Superhero Center for Autism. Documentation of a special need that can benefit from the sensory gym is not required to participate (IEP, IFSP, 504 plan, doctor’s note, current therapist note), but may be requested in some situations.

Superhero

First name*

Last name*

Birthdate*

School district*

Gender*

Super-Sibling(s)

Would you like to register any siblings who may be accompanying your superhero while visiting the Center?

Parent or Guardian

First name*

Last name*

Relationship to Superhero

Address*

City*

State*

ZIP*

Country*

Telephone*

E-mail*

Emergency Contact

Name*

Telephone*

For Data Purposes Only

Child’s diagnosis*

Race/Ethnicity*

Confirmation of diagnosis may be required (IEP, IFSP, 504 Plans, doctor’s verification, etc.)

Release

Parents/Guardians: Please read the releases below and sign at the bottom. This release is valid until redacted in writing by parents.

Release: To the fullest extent permitted by law, I release The Superhero Center for Autism, its officers, directors, employees, and volunteers from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless The Superhero Center for Autism, its officers, directors, employees, and volunteers from any claims arising out of my minor child’s participation in the activity.

Medical: In the event of a medical emergency and when a contact cannot be made in a timely manner to me and/or the emergency contact listed, I give my permission for my child(ren) to receive appropriate medical attention and even be transported to the nearest emergency room via ambulance. In the event of an unforeseen emergency or any accidents, I release The Superhero Center for Autism, its employees and volunteers, and all those related to it, from any liability. I have provided emergency contact numbers and am assured that I will be contacted as soon as possible in the event that there is an emergency.

Photograph release: Occasionally photos and videos may be taken at or by members of The Superhero Center for Autism. I grant permission for The Superhero Center for Autism to post photos and videos including my child(ren) on its website, Facebook page or other social media accounts related to The Superhero Center for Autism.

I agree with the above releases.

Name*

Today’s date*

Parent Pledge

When at the Superhero Center for Autism, as a parent I pledge:

To always be respectful of other superheroes and their families
To support other parents of superheroes in a nonjudgmental way
To respect volunteers by monitoring my child(ren) when they attend The Superhero Center
To make sure my child(ren) are using all equipment in a safe manner
To understand that the volunteers are not here to watch my child(ren)
To ensure that my child is healthy and not posing a risk to others

I have read this pledge and agree to be a “super parent” at The Superhero Center for Autism. I acknowledge that a volunteer may ask me to leave if I am creating an environment that is not safe or supportive to superheroes or their families, or is creating a negative environment at The Superhero Center for Autism.

Name*

Today’s date*

Superhero registration form

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