Adult Social Activities Program “ASAP”

Living with Assistance ASAP membership is FREE for now!

We aim to provide social programming, social events, virtual events, and community outings to connecting individuals AGES 18+ who are looking for a safe place to socialize with others in their community!

REGISTER FOR YOUR MEMBERSHIP BELOW!

ASAP Member Registration Form

Please complete this form ONCE to become a member participate in any of our ASAP Activities including Game Night, Building Confidence Course, social events, etc.

(Individuals must be 18 years or older to be an ASAP member)

After you complete this initial registration, please register for ongoing Game Nights each week HERE or the Building Confidence course HERE!

Participant's Name

First Name

Last Name

Date of Birth

YYYY

Guardian Name (if applicable)

If the individual attending the course is not their own guardian, please put the contact person's name here, and also list this person's email and phone number below.

First Name

Last Name

Contact Cell Phone Number

(###)

###

####

Contact Email

Residential Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical/Behavioral Concerns

Please list any medical/behavioral concerns that LWA should be aware of. This is for your safety and the safety of all staff and members. *LWA staff is not authorized to administer medication

Tell us a bit about yourself!

This is where you can tell us about some of the challenges you face in becoming more independent, any diagnosis that effects your independence, or any other important information that we should know about you that you wish to share!

What activities would you love to see with ASAP?

This can include events at our center, events online, outings, trips, etc.

What games do you enjoy playing?

This can include card games, board games, group party games, etc.

Support Coordinator's Name, Email and Phone Number

If you would like to use your DDD Goods and Services Budget for future programming, please provide us with you support coordinator's name and contact information so we can connect!

Payment Awareness Agreement

By typing your name in the box below, you understand that your card will be kept on file but only charged when you register for an event. Your card will not be used without your consent.

Name on Card

Your card will only be used when you register for an event at this time.

First Name

Last Name

Credit/Debit Card Number

Expiration Date

(If no specific day is determined in expiration date, please just enter "01" in the day place.)

YYYY

CVV/Security Code Number

(Usually 3 or 4 digits located on back of card)

Zip Code for Card

This should be the Zip Code for the address attached to the card you are providing us.

Any questions, additional information, or anything else you want to share with LWA?

Adult Social Activities Program “ASAP”

Living with Assistance ASAP membership is FREE for now!

We aim to provide social programming, social events, virtual events, and community outings to connecting individuals AGES 18+ who are looking for a safe place to socialize with others in their community!

REGISTER FOR YOUR MEMBERSHIP BELOW!

ASAP Member Registration Form

Thank you for becoming an ASAP member!

Please register for ongoing Game Nights each week HERE or the Building Confidence course HERE!

Living with Assistance LLC