WRFN Family Conference 2017 Registration Form

WRFN Family Conference 2017 Registration Form

Family Name: Click here to enter text.

First Names of Adults Attending: Click here to enter text.

Email Address: Click here to enter text.

Address: Click here to enter text.

Cell Phone (please provide a cell phone number if you are registering for childcare to reach you if necessary on the day of the conference): Click here to enter text.

Are you currently connected to WRFN? Yes ☐ No ☐

Lunch will be included. Please list any dietary needs for you and/or your family (gluten free, allergies, etc.). Please indicate if you do not require lunch:

If you are not registering for childcare please disregard the remainder of this form.

Please provide the following information for your child(ren) with disabilities that will be attending the conference. If you feel more comfortable providing your own support person for your child please indicate that in the additional information section. If possible, please send a digital photo of your child(ren) with your registration form.

First Child

Name: Click here to enter text.

Age: Click here to enter text.

What are your child’s needs? Click here to enter text.

Please list medical precautions (ie. allergies, seizures, respiratory, etc.) Click here to enter text.

If 1:1 support is necessary for your child please explain why. We will do our best to accommodate all needs but cannot guarantee 1:1 depending on the number of people registered. Click here to enter text.

Does your child need assistance with toileting? Yes ☐ No ☐

If yes, what level of support &/or equipment is needed?Click here to enter text.

Is your child at risk of wandering/running away? Yes ☐ No ☐

Additional Information: Click here to enter text.

Second Child

Name: Click here to enter text.

Age: Click here to enter text.

What are your child’s needs? Click here to enter text.

Please list medical precautions (ie. allergies, seizures, respiratory, etc.) Click here to enter text.

If 1:1 support is necessary for your child please explain why. We will do our best to accommodate all needs but cannot guarantee 1:1 depending on the number of people registered. Click here to enter text.

Does your child need assistance with toileting? Yes ☐ No ☐

If yes, what level of support &/or equipment is needed?Click here to enter text.

Is your child at risk of wandering/running away? Yes ☐ No ☐

Additional Information: Click here to enter text.

*If you have more than two children with disabilities please provide the same information for each child.

Siblings

If there are siblings that will be attending please fill out the following information:

Name(s) and age(s) of sibling(s): Click here to enter text.

Please list medical precautions (ie. allergies, seizures, respiratory, etc.) Click here to enter text.

Additional Information:Click here to enter text.