Please fill out the form below or download a printable form of the application on the left.  This application must be completed in order to attend any of our events; this is only required for the first event your family attends.

Primary Individual's Name (First, Last): *
Date of Birth: *
Gender: *	----MaleFemale
Primary Diagnosis *
Visual Ability: *	----NormalWears glassesImpaired
Hearing Ability: *	----NormalImpairedWears Hearing Aids
Ambulation Ability *	Walks independently  Uses Cane  Uses Walker  Uses Wheelchair  Wears braces  Needs physical assistance  Is unsteady on feet
Bathroom Needs: *	Independent  Wears diaper/pull-up  Needs reminders to use bathroom  Needs assistance removing clothing  Needs assistance with fasteners  Needs verbal cues  Needs picture cues
Is there a history of seizures? *	----YesNo
List any medications and dosages the individual is currently taking: *
Does the individual have any allergies (food, animal, seasonal)? *
Primary Caregiver's Name: *
Address: *
Primary Phone Number: *
Secondary Phone Number: *
Email Address:
Additional Guest's Name:
Date of Birth:
Gender:	----MaleFemale
Does the individual has special needs?	----YesNo
Additional Guest's Name:
Date of Birth:
Gender	----MaleFemale
Does the individual have special needs?	----YesNo
Additional Guest's Name:
Date of Birth:
Gender:	----MaleFemale
Does the individual have special needs?	----YesNo
Emergency Contact Name: *
Emergency Contact Phone Number: *
Aside from primary caregiver, please list other person(s) authorized to pick up the individual. Must be at least 18 years old. *
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