Participant First Name:    

Select the programs you are interested in the participant attending:

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Educational/Therapeutic Programs:

Unstuck and On Target!Applied UnstuckConversation Programs (e.g. Conversation Club and Conversation Street)PEERSSelf Advocacy Group Tuesday EveningsSelf Advocacy Group Saturday MorningsWhat's Cooking?

Saturday Recreational Programs:

Camp LOLGirls Club

After School Recreational Programs:

Art Tuesdays AND ThursdaysArt Tuesday ONLYArt Thursday ONLYAthletics Tuesday AND ThursdayAthletics Tuesdays ONLYAthletics Thursdays 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.