Register – HangOutHive

First Name*

Last Name*

E-mail Address*

Cell Phone Number*

Street Address*

Password (needed for your membership account)*

Confirm Password (needed for your membership account)*

List your disabilities/diagnoses*

Who assisted you with this application?*

How did you hear about the HangOut Hive?

Tell us why you are interested in joining HangOut Hive?*

What activities or interactions might be hard for you because of your disability?*

Challenges not listed above

Any additional details about activities or interactions that may be hard?

Do you have a debit/credit you can use?*

YESNO

Do you need help from parents or support staff sometimes?*

Support Staff Name

Support's Phone Number

Support's Email Addesss

Do you know any existing member? If so, who?

What positive qualities will you bring to the group?*

What do you want to gain from the HOH community, if invited to join?:*

Birth Date (must be 21+) MM/DD/YYYY*

Membership Requirements*

I understand and accept the membership requirements*

YES - I agree to all of the aboveNo - I need a follow-up call

Conduct Rules*

All information within the HangOut Hive meeting is considered ConfidentialThere will be no drugs or alcoholic beverages consumed at HangOut Hive Events

No vaping or smoking is allowed with the proximity of a HOH meeting or event.All members will treat other members with respect and kindness:

No harassment, threats of violence, no retaliation nor discrimination will be tolerated.Any action or communication showing disrespect and causing fear and/or humiliation will result in that member being removed from the group

By submitting this membership application I agree to be bound by all Conduct Rules*

YES - I agree to conform with all conduct rulesNO - Please contact me for explaination

** Emergency Contact Information **
In case there is an emergency during an event, we require emergency contact information for each member. The emergency contact listed must be aware of your diagnoses, medications, treatment plan, and be within 30 miles of Rockville, MD.
A member’s emergency contact cannot be another member nor can we accept the individual as their own emergency contact.

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact email*

Is there anything else you would like to share?