Adult Social Groups Registration : Adult Social Groups : Programs : What We Do : Club 21 Learning and Resource Center

Young Adult's Name:

Birthday

Age

This program is for those 18+ years of age

Gender

Address:

City

Zip Code

Teen's/young adult's Email

Teen's/young adult's Phone Number:

Parent's Name

Parent's E-mail:

Parent's Phone

Does your child have any behavioral triggers or are there any situations that would require further assistant/intervention?

What is your Teen's/young adult's main method of communication

i.e. AAC device, sign language, verbal communication, etc.

Does Club 21 have permission to release photos of your young adult:

by clicking "yes" you give your consent

Please read the statement below and check the box to acknowledge that you have read the statement and you agree to its terms.

The safety of all participants is critical to the success of this program. If any participant compromises the safety of the group by disobeying rules determined by the location of the activity or given by the facilitators, parents/guardians will be asked to provide necessary supports during future events. If the family is not able to provide requested supports, the participant will be removed from the social group and the participation fee will not be refunded.

I acknowledge the statement above.

Roller Skating - Sept. 20, 2025

$27- Roller Skating

Dragon Boat Experience & Picnic - Oct 19, 2025

$15- Dragon Boat

Color Me Mine Pottery Painting - Nov. 14, 2025

Color Me Mine is Full Registration is closed for this event.

Escape Room & Dinner - Jan. 9, 2026

$45.00 - Escape Room

Indoor Rock Climbing - Feb. 22, 2026

$35-Indoor Rock climbing

Sporting Event (TBD) - Mar. 28, 2026

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Miniature Golf/Bumper Boats - Apr. 18, 2026

$30 - Miniature Golf/Bumper Boats

Hike and Picnic - May 17, 2026

$15 - Hike and Picnic

Beach Trip - June 5, 2026

$15 - Beach Trip

If you are using Self Determination funds, please fill out this information:

Independent Facilitator name

Independent Facilitator email

Financial Management Service (FMS)

Service Code for Invoice

According to your spending plan

FMS email

Payment Option

I will be paying for the program
I will be using Self Determination funding or applying for a scholarship (which is a separate form on the About Club Connections page).

Credit Card Information

Cardholder Name

Credit Card #

Expiration Date

Security Code

Billing Zip Code

Make this a recurring payment?

No, this is a one-time payment.
Monthly

Make this a recurring payment?

Your total payment will be .

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Adult Social Groups Registration

Social Groups Registration

Credit Card Information

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