Pioneer Resources

Email:*

Confirm Email:*

Enter Password:*

Confirm Password:*

First Name:*

Last Name:*

Middle Initial:

Nickname person goes by:

Date of Birth:*

CMH / Health West Case Number:

Special Interests:

Street:*

City:*

County:*

State:*

Zip:*

Cell Number:

Home Number:*

Program:*

Holland

Muskegon

Does this person drive?

Yes

Is person able to use public transportation?

Yes

Does this person have a felony conviction?*

Yes

If yes, please describe:

Currently on probation?*

Yes

If yes, name of probation officer:

Ethnicity:*

Gender recognized as:*

Marital Status:*

Spouse's name if married:

Disability:*

Mobility:*

Person making the referral:

Title:

Contact Information:

If personal care assistance will be needed, please describe briefly:

If behavioral supports will be needed or requested, briefly describe:

Date of Last Person Centered Plan, IEP, or other individualized plan of service:

Primary Emergency Contact

Name

Relationship

Phone

I acknowledge that there are risks when participating in any recreation or leisure activity and assume responsibility for my participation in events. I understand that the Leisure and Recreation Club, an organization and/or club members shall not be held responsible for injury incurred during a club meeting or event. I agree that as a club member, I would adhere to standards set forth in the club by laws. Furthermore, if I require assistance, I will provide my personal care attendant for the activity, at my own cost and risk.

I hereby allow the release of my photo/information for marketing and documentation purposes.

I would rather have my LARC Calendar emailed to me than mailed through the United States Post Office. Marking 'Yes' means I will not receive a copy in the mailbox. I know that I can change that at anytime by calling Lora Brink at 231-773-5355 ext.1235.*

Yes