Class Enrollment
Please provide your information to be enrolled in one of our classes.
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Today's Date *
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Who is registering today? *
If you are a parent or guardian, what is your name?
If you are a parent or guardian, what is your email?
If you are a parent or guardian, what is your phone number?
Personal and Medical Information Waiver:  Do you give Disability Network Wayne County Detroit permission to collect your personal and medical information for the purposes of qualifying and certifying you for eligibility for our disability programs  This is with the understanding that the our agency provides trained, HIPPA certified professionals who are explicitly prohibited from sharing any personal or medical information at any time, for any reason, with any unauthorized person?  Please reply Yes or No *
PHOTO RELEASE FORM FOR MINOR                                   I, _____________________________, the parent or legal guardian of the participant registered person, grant Disability Network Wayne County Detroit my permission to use the photographs described as marketing and educational for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content.  Furthermore, I understand that no royalty, fee or other compensation shall become payable tome by reason of such use.  TYPE PARENT NAME OR ADULT PARTICIPANT NAME  - If you do  not wish to give permission for your image to be used, please type - "Do Not Use".   *
URBAN GARDEN PARTICIPANTS ONLY:  Please type your name (parent's name for minor) that you have been informed of the following statement:  Please be advised that working in the garden outside you will encounter several allergens. You will come into contact with pollen, bees, and different types of vegetables and flowers that may bring on allergic reactions. Please let counselors and staff know if you have any allergies that may be present with this summer program.  Please sign acknowledging you have read the above information and are aware of the possible allergic reaction if you have allergies against any of the items found on the farm. *
If you have any known allergies that we must be made aware of, please indicate those allergies here:  if you have none, type NONE. *
If you have a physical or mental health disability and need reasonable accommodations to perform the essential functions to participate in our programs. Should you need any help completing this form, or if you have any questions about this form, please speak to the Disability Network Wayne County Detroit’s Human Resource Director at 313-618-1513.   Please describe the accommodation(s) you are requesting. If you do not require any accommodations, please type:  NONE *
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