Participant's Name:
First Name
Middle
Last Name
Name as you would like it to appear on name tag:
Age/Date of Birth:
Gender:
Address:
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Email Address:
Phone Number:
Fun Fact About You:
Emergency Contact and Phone Number:
Health Concerns:
Wheelchair:
Special Communication Needs: If Yes, please explain:
Sensory Issues/Concerns (strobe lights, camera flashes, loud noises,etc.):
Allergies: (Please list all)
Food Needs: (food cut up or pureed, gluten free, etc.)
Parent/Caretaker Name (s):
Parent/Caretaker Phone Number:
Parent/Caretaker will be:
If enjoying the Respite Room, how many? (The Respite Room is a private area where parents/caretakers of the guests can spend the evening enjoying food, entertainment, and rest while remaining onsite during the event.)
Care Provider Agency: (If Applicable)
Care Provider Agency Phone Number:
Agency Chaperone Name:
What is the participant's favorite song?
Additional Notes or Concerns: