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Family Member to Register

First Name

First Name is required.

Last Name

Last Name is required.

First Name as you would like it to appear on nametag

First Name as you would like it to appear on nametag is required.

Gender

Gender is required.

Birthday

/ / Birthday cannot be a future date.

Email

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1 Fun Fact

Emergency Contact during Event

Emergency Contact during Event is required.

Emergency Contact Phone

Emergency Contact Phone is required.

Health Concerns

Dependent on Wheelchair / Accessibility Device

Yes No

Dependent on Wheelchair / Accessibility Device is required.

Current Communication Skills

Current Communication Skills is required.

Sensory Issues

Sensory Issues is required.

Allergies (leave blank if none)

Specific Food Needs

None Food Cut Up Gluten-free Dairy-free Diabetic-friendlySpecific Food Needs is required.

Independent in Bathroom

Yes No (explain)

Independent in Bathroom is required.

Does this guest have a paid waiver Buddy attending with them?

Yes No

Does this guest have a paid waiver Buddy attending with them? is required.

Does this guest have an arrangement with someone to be their Buddy for the evening?

Yes No

Does this guest have an arrangement with someone to be their Buddy for the evening? is required.

Will Need Medication Administered during Event

Yes No

Will Need Medication Administered during Event is required.

Additional Notes/Concerns You Would Like Us to Be Aware Of

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