Hussman Center for Adults with Autism: Emergency Contact and Participation Agreement Form

Your Name - first & last

Emergency Contact Name

Emergency Contact Phone Number

Alternate Emergency Contact Name

Alternate Emergency Contact Phone Number

By checking this box I agree that my emergency contact may be called in the event of an emergency.

Please read all agreement sections below and check each box indicating your agreement.

By checking this box and clicking the submit button I agree to the Social Group Guidelines

All Social Group attendees must follow the Hussman Center Behavior Standards. These Behavior Standards and guidelines are in place to support a safe and positive experience for everyone who attends Social Groups, including staff and all guests.

I will demonstrate a respectful attitude towards others at the Social Group.
I will conduct myself in a manner that does not interfere with others' participation or safety.
I will maintain confidentiality. Personal information about other participants will not be repeated to or shared with others.
I have read the Hussman Center Behavior Standards and I understand and agree to follow all Hussman Center Behavior Standards.
I agree to notify Hussman Center staff if I am uncomfortable or upset.
I understand that if I do not follow the above guidelines and the Hussman Center Behavior Standards I may need to leave Social Group and may not be able to continue to participate.

By checking this box and clicking the submit button I agree that I have read and will follow the Hussman Behavior Standards - linked below

https://www.towson.edu/iwb/centers/hussman/programs/documents/hcaa-behavior-standards.pdf

Contact Information