Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Companionship's Club Pierce Registration

  1. Companionship's Club Pierce

    For ages 20-30 years.

  2. Gender*

  3. Wednesdays at Meridian Habitat Park and Community Center (8 am to 3 pm)

  4. January 2020

    Register by Jan. 10

  5. February 2020

    Register by Jan. 31

  6. March 2020

    Register by Feb. 28

  7. Fridays at Lakewood Community Center (8 am to 3 pm)

  8. January 2020

    Register by Jan. 10

  9. February 2020

    Register by Jan. 31

  10. March 2020

    Register by Feb. 28

  11. 1-to-1 assistants

    All staff, volunteers, care providers, and 1-to-1 assistants at Club Pierce are required to have completed, submitted, and approved background checks prior to participating. This process can take up to a week to complete.

  12. Is a 1-to-1 assistant required?*

  13. Is the participant taking medicine of any kind?*

  14. Will the participant need to take medications while at Club Pierce?*

  15. Does the participant have allergies?*

    (Food, medicine, etc.)

  16. Are there any special precautions or life-threatening health concerns we should be aware of?*

  17. Does the participant have blackout spells?*

  18. Can the participant dress and change clothes alone?*

  19. Will the participant take and follow basic instructions or directions?*

  20. Is the participant able to read independently?*

  21. Is the participant able to write independently?*

  22. Can the participant independently ambulate for a distance of at least two city blocks without needing to stop?*

  23. Does the participant use any special equipment to ambulate?*

    (walker, wheelchair, crutches, etc.)

  24. Does the participant become overwhelmed in some situations?*

  25. Bathrooms

    Club Pierce will be out in the community the majority of the time and bathrooms will not always be immediately available.

  26. Is the participant able to identify and indicate that they need to use the bathroom at least 15 minutes before it becomes an emergency?*

  27. Will the participant use the bathroom when instructed?*

  28. Can the participant use the bathroom without assistance?*

  29. Will the participant use Pierce Shuttle to transport to and/or from Club PIerce?*

  30. Is DSHS/DDA providing financial assistance?*

  31. Consent

    I give my consent to Pierce County Parks and Recreation to photograph my child and to use such pictures and/or stories in connection with the program activities. I hereby request that my child be permitted to attend the Club Pierce recreation program for individuals with special needs and authorize the director of the program to act for me according to their best judgement and ability in any emergency requiring medical care.

  32. Please type in your first and last name (Parent or Legal Guardian).

  33. Reminder

    Participants should bring a sack lunch each day.

  34. Pierce County Parks and Recreation staff will contact you for registration confirmation and payment (if paying by credit card or DSHS/DDA funding). If you have not been contacted within two business days, please call (253) 798-4199.

  35. Leave This Blank:

  36. This field is not part of the form submission.