Hammonton adult form | mslindsayslilrockers

Autism Movement Therapy Registration Form: Teens/Adults 13+, Hammonton, NJ

MUST BE 18 YEARS OR OLDER TO COMPLETE THIS FORM

PARTICIPANT'S LAST NAME

PATICIPANT'S FIRST NAME

SEX

MALE

FEMALE

MERMAID

OTHER

PLEASE LIST ALL ALLERGIES

PLEASE LIST ALL PHYSICAL CONDITIONS OR IMPAIRMENTS, COGNITIVE LIMITATIONS, SPECIAL NEEDS OR CHALLENGES

IS THERE ANYTHING ELSE MEDICALLY THAT WE SHOULD KNOW ABOUT?

PLEASE SHARE WITH US ANYTHING THAT TENDS TO MAKE THE PARTICIPANT UPSET OR UNCOMFORTABLE. GENERALLY, WHAT ARE THEIR ACTIONS WHEN THEY FEEL THIS WAY? WHAT CAN WE DO TO HELP THEM IF THIS WERE TO HAPPEN DURING A CLASS?

THE FOLLOWING IS REQUIRED IF PARTICIPANT IS UNDER 18. IF YOU ARE REGISTERING YOURSELF FOR THIS CLASS, YOU MAY PUT YOUR OWN INFORMATION IN OR YOUR PARENT'S INFORMATION.

GAURDIAN'S LAST NAME

GAURDIAN'S FIRST NAME

PHONE

ADDRESS

EMAIL ADDRESS

EMERGANCY CONTACT FULL NAME

RELATIONSHIP TO CHILD

EMERGANCY CONTACT NUMBER

RELATIONSHIP

IS THERE ANYTHING ELSE WE SHOULD KNOW?

Attention: Your spot will not be secured until you pay for the class *

Thanks for submitting!