Registration Form

Participant Name:

Birthday:

Address:

Contacts- Home:

Cell:

Email:

Participant Preferred Pronouns:

Emergency Contact Name and Phone Number:

Preferred Contact for Program, Billing, and Registration Information (name, email, phone number):

Program Registration:

Documented Disability:

Areas of Interest / Dislikes:

Communication: VerbalNon Verbal

Communication Used:

Level of Mobility: AmbulatoryAmbulatory / Assistive DevicesManual/Power Wheelchair (Self-Propelled)Wheelchair (Assistance Needed)

Photos: YesNo

Level of Support Needed: IndependentIndependent/Some Assistance1 on 1 Support Needed

If 1 on 1 support needed, please describe level of support:

Allergies/Dietary Restrictions:

Other Special Considerations:

Broker Name:

Telephone:

Email:

Financial Intermediary Name:

Telephone:

Email:

Address:

Print Name

Mailing Address:

Signature:

Guardian Signature (If under 18):

I agree to the terms and conditions