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+1 877-456-0101
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Info@lovebeyondautism.org
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2nd Annual Gala
1st Annual Gala
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Home
About Us
Care Partner
Gallery
3rd Annual Gala
Snow White
4th Annual toy Drive
Hearts Without Walls
Viejas Casino Bus Trip Fundraiser
2nd Annual Love Beyond Autism Walk
1st Annual Love Beyond Autism Walk
Pink Pump Affair
2nd Annual Gala
1st Annual Gala
Prom Pictures
Social Outing
Videos
Newsletter
Contact Us
Guest Comments
Your Account
Donate
Home
About Us
Care Partner
Gallery
3rd Annual Gala
Snow White
4th Annual toy Drive
Hearts Without Walls
Viejas Casino Bus Trip Fundraiser
2nd Annual Love Beyond Autism Walk
1st Annual Love Beyond Autism Walk
Pink Pump Affair
2nd Annual Gala
1st Annual Gala
Prom Pictures
Social Outing
Videos
Newsletter
Contact Us
Guest Comments
Your Account
Home
About Us
Care Partner
Gallery
3rd Annual Gala
Snow White
4th Annual toy Drive
Hearts Without Walls
Viejas Casino Bus Trip Fundraiser
2nd Annual Love Beyond Autism Walk
1st Annual Love Beyond Autism Walk
Pink Pump Affair
2nd Annual Gala
1st Annual Gala
Prom Pictures
Social Outing
Videos
Newsletter
Contact Us
Guest Comments
Your Account
Donate
3-D Dream DBA Senior Lifestyle Transportation
Senior Lifestyle Signup & Release of Liability Form
Thank you for your interest in joining the 3-D Dream DBA Senior Lifestyle Transportation Community! Please complete this form to participate in upcoming outings, transportation services, lunches, day trips, social activities, and community events.
⚠️ IMPORTANT: This completed form MUST be on file before participation in any 3-D Dream DBA Senior Lifestyle Transportation trip, transportation service, or outing can be approved.
PARTICIPANT INFORMATION
Full Name
(Required)
Date Of Birth
(Required)
MM slash DD slash YYYY
Phone No
(Required)
Email Address
(Required)
Address
(Required)
Street Address
State / Province / Region
ZIP / Postal Code
EMERGENCY CONTACT
Emergency Contact Name
(Required)
Emergency Contact Phone
(Required)
MOBILITY + MEDICAL
Do You Require Any Mobility Assistance?
(Required)
No
Cane
Walker
Wheelchair
Other
Tell us more...
(Required)
Medical Conditions Or Allergies
(Required)
Medications We Should Be Aware Of
(Required)
PREFERRED ACTIVITIES
Select your preferred activities
(Required)
Lunch Outings
Botanical Gardens
Shopping Trips
Scenic Drives
Casino Trips
Movie Days
Beach Trips
Social Events
Transportation Services
Other
Tell us more...
(Required)
REFERRAL SOURCE
How did you hear about us?
(Required)
Facebook
Instagram
Friend/Family
Community Event
Other
Tell us more...
(Required)
LEGAL AGREEMENT
(Required)
I agree to the privacy policy.
RELEASE OF LIABILITY & PARTICIPATION AGREEMENT
I understand that participation in 3-D Dream DBA Senior Lifestyle Transportation services, outings, and recreational activities involves travel and participation in community-based events and activities.
I voluntarily agree to participate and acknowledge that while every effort will be made to provide a safe, supportive, and supervised environment, 3-D Dream DBA Senior Lifestyle Transportation and its representatives cannot guarantee against accidents, injuries, illness, delays, weather conditions, traffic conditions, or unforeseen circumstances.
By signing below, I agree to the following:
• I voluntarily choose to participate in 3-D Dream DBA Senior Lifestyle Transportation services, outings, and activities.
• I understand transportation may be provided for certain outings, events, and activities.
• I understand that some outings may involve walking, outdoor environments, restaurants, shopping areas, public attractions, and other community settings.
• I understand participants are responsible for personal purchases unless otherwise stated.
• I agree to follow safety instructions and respectful behavior guidelines during all outings and transportation services.
• I release and hold harmless 3-D Dream DBA Senior Lifestyle Transportation, its staff, volunteers, drivers, and representatives from liability for injuries, accidents, losses, theft, damages, delays, or medical emergencies that may occur during participation, except in cases of gross negligence.
• I authorize emergency medical treatment if necessary and understand emergency services may be contacted if needed.
• I understand that photographs and videos may be taken during outings and activities for promotional, website, and social media purposes unless I submit a written request declining permission.
Signature
(Required)
Full Name
(Required)
Date
(Required)
MM slash DD slash YYYY
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