JA Beranis

REGISTRATION FOR FRIENDSHIP CLUB

Complete the form below to become a member of the club to receive details for each meeting.

IMPORTANT REMINDER

Please add info@autismakron.org to your email contact list to ensure ASGA emails get to your inbox. If you do not see a confirmation email in your inbox, please check your spam or junk folder.

Heard about event *

First ASGA Event *

Yes

GUARDIAN INFORMATION

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Email *

Confirm Email *

PARTICIPANT INFORMATION

Name of Child Participating *

Child's Birthdate *

Any food allergies

In the box below, please list some of your child's interests or hobbies.

In the box below, please provide any detailed information regarding your child's diagnosis that will help us work with your child safely and effectively. Explain any health/medical conditions or concerns and any related special instructions.

Please check any info that you would like to share with us:

My child does not need assistance

My child needs physical assistance to participate

Has difficulty hearing or expressing spoken language (or uses an assistive device)

Tends to wander or run away from groups

Can only have snacks brought from home

What do you hope your child will gain by attending the Friendship Club? Choose the sentence that describes what is most important to you.

Interacting with kids the same age

Participating in a planned activity

Practicing social skills

Making friendship connections

Other

Our goal is to make connections for families. Would you like to be added to a contact list that is distributed to the group?

Yes