Crew Night Registration

Student's Info

First Name*

Last Name*

Birthday*

Medical Diagnosis*

In order to best serve your student, please list any medical diagnosis. Examples: Autism, Developmental Delay, Down Syndrome, Cerebral Palsy, etc.

Please list any allergies

What is the primary way the student communicates?*

Please describe your child’s main mode of functional communication

Does the student require ambulation or a mobility device? *

Examples: wheelchair, walker, braces, etc.

YesNo

Does the student require assistance with eating/drinking and or using the restroom? *YesNo

Describe Student's strengths/abilities along with their challenges/frustrations

My child is uncomfortable with or has an aversion to:

What activities does your student enjoy?

Does your student have any behaviors that might be harmful or disruptive to themselves or others?YesNo

If answered yes above, What do those behaviors typically look like, and what is beneficial in de-escalating and calming those behaviors?

What physical or behavioral supports are most beneficial for your child?

Is there any other information you'd like us to know?

First Name*

Last Name*

Phone Number*

Email*

Address*

Preferred Contact Method*

Emergency Contact Name*

Emergency Contact Phone Number*

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