Participant Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Primary Phone Number *

By entering your number, you agree to receive mobile messages regarding programming, standard rates apply, Text back UNSUBSCRIBE to stop.

(###)

###

####

Secondary Phone Number

(###)

###

####

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name(s) *

First Name

Last Name

Health History *

Please check any of the following that apply or have been diagnosed for your child.

Autism Spectrum Disorder

Down Syndrome

ADHD

Cerebral Palsy

Developmental Delay

Sensory Processing Disorder

Speech Delay

Other (Explain below)

Physical Function *

Please check any that apply to your child.

Able to walk without assistance

Able to walk up 4 stairs with minimal/no assistance

Uses a walker device

Uses a wheelchair

Uses braces or supports during the day

Uses sensory aids such as headphones, certain clothing etc

Gross motor delay (walking, running, kicking, large movements)

Fine motor delay (holding utensils or pen, smaller movements)

By typing my name below I am verifying the listed information is true and accurate to the best of my abilities. *

First Name

Last Name

Photo Release *

I consent to and authorize the use or reproduction byJustin’s Place of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

I consent

I do not consent

By signing below I indicate that I consent or do not consent to the above stated photo release. *

First Name

Last Name