Sibshops Registration

Sibshop Registration Form

Child's Information

First Name *

Last Name *

Date of Birth *

Month

Day

Year

Gender *

Grade *

Does this child recieve any special services (e.g., counseling, speech therapy, special education)? *

Parent's Information

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Home Phone *

Cell Phone *

Email *

Sibling with Special Needs Information

First Name *

Last Name *

Date of Birth *

Month

Day

Year

Gender *

Nature of disability *

School *

Other Siblings

Name	Birthdate	Gender

What are your reasons for enrolling your child in the Sibshop program? *

Do you have any concerns about enrolling your child in the Sibshop? *

Do you have an particular topics that you like addressed during the Sibshop

Food Allergies / Restrictions *

Please provide any other information that you feel will make this an enjoyable and education experience for your child *

Signature

I assume all risks and hazards of the conduct of the program and release from responsibility any person providing transportation to and from activities. In case of injury, I do hereby waive all claims or legal actions, financial, or otherwise against ADEC, Union Center Therapy, or the Elkhart YMCA, their elected officials and employees, the organizers, sponsors, supervisors or any volunteer connected with the program. In absence of a signature, payment of fees and participation in the program shall constitute acceptance of the conditions set forth in the release. I grant full permission to use any photographs, videotapes, motion pictures, recordings, or any other record of this program for any purpose.

Signed *

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Sibshops Registration

Sibshop Registration Form

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Sibshops Registration

Sibshop Registration Form

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