Event Series: Fine Motor Open Play with Amy OT

Fine Motor Open Play with Amy OT

Name: Fine Motor Open Play with Amy OT
Start: 2025-04-05T10:00:00-04:00
End: 2025-04-05T12:00:00-04:00
Location: Club DREAMS

April 5 @ 10:00 am - 12:00 pm

First Name*

Last Name*

Age*

Address

Email*

Phone*

To allow us to continue to understand and adapt to the needs and barriers of our participants we ask you to consider answering the following optional demographic data collection questions. As a nonprofit, grant support is a large percent of our funding and this demographic data is key to grant requests.

Race

Primary language spoken at home

Does your family experience economic hardship?

Yes

Does your family experience transportation difficulties or lack of access?

Yes

How many participants will be attending?

Please pay below with purchase of tickets for all attending if this is a paid program.

Do you permit photos and allow Club DREAMS to utilize for marketing?*

Will you child need assistance in the bathroom? If so, do you permit Club DREAMS staff to assist?*

Allergies? Other things we should know?*

Provide Emergency contact number for 2 people.*

Are you planning on attending weekly or occasionally? If weekly please contact us if there is a week you are not attending, if sporadically you must register for each week attending.*

Please tell us about your child and how we can best support them.

Does your child have Down Syndrome, Autism, other condition- please provide more info so we can best support your child.*

-Any member(s) under the age of 6 years old must have an adult accompany them at all times within the suite, with the exception of select designated times such as Kids Night Out events. Guardians may help themselves to refreshments and relaxation in the welcome area. -Any member(s) between the ages of 7-10 may be dropped off at the center, with the exception that an adult guardian must stay within the Suburban Square shopping plaza and can be reached immediately by phone if needed (with the exception of designated events such as Kids Night Out). -Member(s) ages 11+ may be dropped off at the center, and adult guardians must be able to be reached by phone if needed.*

How did you hear about us?*

Best method to contact*

Check the box to acknowledge and accept the General Liability Clause*

Read the detailed General Liability Clause

Your Name (Being served as a signature)*