Midweek Movement - Parent Participation Application Form

Midweek Movement - Parent Participation Application Form

Thank you for your interest in participating in the WAAA Dance & movement Class. Please fill out this form carefully so we may get to know you! Washington Autism Alliance and Advocacy, a Washington State non-profit organization, conducts criminal background checks on all volunteer applicants through the Washington State Patrol. WAAA Dance Class (or other adult) participants require background checks and are conducted through the Washington Autism Alliance and Advocacy.

(* Required)

Name *______

Email *______

Phone *______

Address______

______

Birthdate * (mm/dd/yyyy) ______

Gender * (required for background check)

_____Male

_____Female

Childs Name*______

Birth date* (mm/dd/yyyy )______

Address*(if different from parent)______

Childs Name*______

Birth date* (mm/dd/yyyy )______

Address*(if different from parent)______

Childs Name*______

Birth date* (mm/dd/yyyy )______

Address*(if different from parent)______

Emergency Contact Information*

Name______

Phone______

Address______

Name______

Phone______

Address______

Name______

Phone______

Address______

Please list activities or projects your child may be interested in*:

Does your child have any life threatening allergies or health conditions? *

Is there any information that would help us to provide a more enjoyable social experience for your child? *

Please read the Parent Participation Disclosure Statement below.

To participate in The WAAA Dance Class I understand that I must not have been convicted of any of the following:

(a) Convicted of any crime against children or other persons;

(b) Convicted of crimes relating to financial exploitation of a vulnerable adult;

(c) Convicted of crimes related to drugs;

(d) Found in any dependency action under RCW 13.34.040 to have assaulted or exploited any minor or to have physically abused any minor;

(e) Found by a court in a domestic relations proceeding under Title 26 RCW to have abused or exploited any minor or to have physically abused any minor;

(f) Found in any disciplinary board final decision to have abused or exploited any minor or developmentally disabled person

(g) Found by a court in a protection proceeding under chapter 74.34 RCW, to have abused or financially exploited a vulnerable adult.

I also recognize that Aspire Girls will make a Request for Criminal Background History as ordained in the Child/Adult Abuse Information Act: RCW 43.43.830 through 43.43.845

Have you been convicted of any crimes listed in article (a) through (g)? *

Yes______No______

Please e-mail completed application to