Participant First Name:    

Select the programs you are interested in the participant attending:

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Educational/Therapeutic Programs:

Unstuck and On Target!Conversation Programs (e.g. Conversation Club and Conversation Street)Self Advocacy Group Tuesday Evenings

Saturday Recreational Programs:

Camp LOLGirls Club

After-School Recreational Programs:

Art Thursdays ONLYAthletics Tuesdays AND ThursdaysAthletics Tuesdays ONLYAthletics Thursdays ONLYCooking Tuesdays ONLY

Participant Information

  Check here if participant information is the same as last session.  Or fill out the fields below with updated information.

Street Address:   

Address Line 2:    

City:   

State/Province/Region:   

Postal/Zip Code:   

Participant lives with:    Both parentsMotherFatherOther (please specify)   Other please specify:   

Parent/Guardian Information

Parent/Guardian 1

Name:   

Relationship to participant:   

Primary Phone Number:   

Alternate Phone Number:   

Email:   

Parent/Guardian 2 

Name:   

Relationship to participant:   

Primary Phone Number:   

Alternate Phone Number:   

Email:   

Click "Submit" below to complete your application.