Register

Name of person completing this form?(Required)

What is your relationship to the participant?(Required)

Your email address?(Required)

Your cell phone number?(Required)

Name of participant?(Required)

Date of birth of participant?(Required)

Address of participant? (If residing in group home, use parent/guardian address)(Required)

Please list any diagnosis or disabilities(Required)

If on a County Boad of Developmental Disability Waiver, please check which one?(Required)

Individual Option Waiver (I/O Waiver)

Level One Waiver

SELF Waiver

Not yet on a Waiver

Other:

Please list mobility limitations here:(Required)

Name of School or Day Program he/she attends?(Required)

How did you hear about Recreation Club?(Required)