Name

First Name

Last Name

Cell Phone

(###)

###

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Email Address (We will use this email address to communicate with you.)

Will You Need Childcare For This Event?

Free childcare is provided for Birth - 6th grade with advance registration.

List Names And Ages Of Children Needing Childcare:

If Your Child Needing Childcare Is Special Needs, Please Fill Out The Following Information Completely:

Child's Name:

Gender:

Date of Birth

YYYY

Grade (if applicable):

Are There Any Medical Conditions or Diagnoses Of Which We Should Be Aware?:

Do You Give Permission For Your Child To Be Given Snacks? Candy? Both?

Does Your Child Like (Add All That Apply): Goldfish / Graham Crackers / Animal Crackers / M&Ms / Skittles

Does Your Child Have Any Food Allergies? If YES, Please List:

Will Your Child Tell Us If He/She Needs To Use The Restroom?:

Your Child Gets Along With Others:

How Does Your Child Life To Spend His/Her Free Time? What Are His/Her Likes and/or Dislikes?:

Please Describe Some Of The Things/Situations That Your Child May Be Fearful Of, Sensitive To, And/Or Reluctant To Try:

What Are Your Child's Best Strategies For Calming Down?:

Are There Key Words Or Phrases To Use?:

Please Share Any Other Information That Would Be Helpful To Your Child's Leaders: