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Please complete the registration form below. All required information must be provided before submitting your registration.
Social Recreation Community Hub Registration 2026
Registration Form 2026
REGISTRATION & AVAILABILITY
Registering for:
Soc Rec in-studio
Online Author
Gamer Days in-studio
DAYS AVAILABLE
Any
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
TIME AVAILABLE
Morning
Afternoon
Evening
PARTICIPANT INFORMATION
Participant's Name
Gender
Male
Female
Date of Birth
Age
Attending School
Yes
No
Home School
LEVEL OF CARE NEEDED
None
Minimal
Often
Always
Please explain level of care: *Please note that participants are required to provide their own assistant if unable to fully participate in games or activities.
PARENT / GUARDIAN / CONSERVATOR INFORMATION
Name
Email
Address
Primary Phone
Alternate Phone
EMERGENCY CONTACT INFORMATION
PRIMARY CONTACT
Name
Relationship
Phone
SECONDARY CONTACT
Name
Relationship
Phone
MEDICAL CONDITIONS OR NEEDS
Medical conditions or needs our instructors should know about: *Please note that we are unable to distribute any medications.
Individualized needs / accommodations:
PHOTO & MEDIA CONSENT
Look at Charles/Social Recreation Hub may share highlights in local publications, Facebook/Instagram, website; respect privacy. By initiating below, user gives Look at Charles and affiliates permission to use photos/video of self/child/participant for program-related print/digital/social media; full faces or names will not be published, mainly side/back views; consent may be withdrawn in writing; no payment claim.
Initials:
I understand and agree to the photo and media release above.
SIGNATURES & AGREEMENT
By signing below (electronically or by hand), you confirm that you have read, understood, and agree to all sections of this document. Your electronic signature carries the same legal weights as a handwritten signature.
Parent/Guardian Signature
Date
Print Name
Minor Participant Name (if applicable)
Adult Participant Signature (if applicable)
Date
Print Name
REGIONAL CENTER / FMS INFORMATION
IF Name
IF Email Address
RC Coordinator
RC Coordinator Email
FMS Name
FMS Email Address
SUBMIT REGISTRATION
