Event Registration

Back to Event Detail

Exceptional Days | Ages 18+ on Tuesday, September 10, 2019 @ 10:00 AM

-
PLEASE FILL OUT THE BELOW FORM FOR THE STUDENT ATTENDING OUR EXCEPTIONAL DAYS PROGRAM.
Your Date of Birth (MM/DD/YYYY):::
Example: 5' 8"
Weight:::
Eye Color:::
Allergies:::
If Yes, what allergies do you have?:::
Medications (Note: Volunteers are not able to administer medications):::
Dietary Restrictions:::
Known Medical Conditions:::
Emergency Contact Name:::
Emergency Contact Phone :::
*Emergency Contact Email:::
Emergency Contact Address (If different then registrants address):::
Level of Supervision:::
Wheelchair:::
In order to properly welcome your loved one each week, we would love to know a little bit about him/her and any accommodations that would be helpful:::
Would you like us to provide a one-on-one support volunteer with your loved one?:::

By clicking next, I am committing to the above guidelines.