Dance 1 Workshop LMP Q1 2023 Registration

Jake's House Virtual Dance Workshop

Thursdays 6:30pm-7:30pm
*Note: Please fill out a seperate registration form for every participant, even if they live in the same household and are using the same device.*
Are you filling out this form on behalf of the participant (for example, your child)?

Yes No, I am filling it out for myself
Please fill out these questions with YOUR information:
Name

First Name Last Name
What is your relationship to the participant?

Parent Caregiver Grandparent Other Family Member Foster Parent Other
Please fill out the rest of this registration form with the PARTICIPANT'S information:
Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please select your DSO Region

Central East (Durham, Haliburton, Peterborough, Simcoe) Central West (Halton, Peel, Waterloo, Wellington) Eastern (Ottawa, Renfrew) Hamilton-Niagara (Brantford, Hamilton, Niagara, Norfolk) North East (Muskoka, Nipissing, Parry Sound, Timiskaming) Northern (Dryden, Sault Ste. Marie, Sudbury, Thunder Bay) South East (Frontenac, Hastings, Lanark, Prince Edward) South West (Chatham-Kent, Essex, Windsor, London, Oxford) Toronto (Etobicoke, North York, Scarborough, Toronto) I live outside of Ontario
If you are unsure which DSO Region you are a part of, click HERE to find out.
Phone Number (Best to be reached for program information) *
Birth Date *

Month Day Year
E-mail (Best to be reached for program information) *
example@example.com
Gender *

Male Female Gender non-conforming Prefer not to say Other
Current Level of Education

Elementary Junior High High School Some College / University Post-degree training
Have you been diagnosed with autism? *

Yes No
What is your diagnosis? If you have received multiple diagnoses, please specify the most recent diagnosis.

Autistic Disorder Childhood Disintegrative Disorder PDD-NOS Asperger Syndrome Social (Pragmatic) Communication Disorder Autism Spectrum Disorder No Diagnosis Yet Received Other
Do you understand English appropriate for your age? *

Yes No Prefer not to say
If you speak a language at home other than English, please list.
How do you typically communicate? *

Verbal: spoken sentences Verbal: phrases or words Non-verbal: uses a device (e.g. computers), pictures, or sign language Minimal communication: may use vocalizations
Currently, how many community activities are you involved in, outside of school and therapy? *

I do not engage in extracurricular activities 1 community activity 2 community activities 3 or more community activities
How many of these activities are with Jake's House? *

All Most Some None
Have you participated in virtual activities or workshops (not including school) in the past? *

Yes No
Which of the following, best describes your comfort level participating in previous virtual activities or workshops (outside of school)? *

Mostly negative Somewhat negative Neutral Somewhat positive Mostly positive Not applicable
Which of the following, best describes your comfort level participating in previous social experiences (outside of school)? *

Mostly negative Somewhat negative Neutral Somewhat positive Mostly positive Not applicable
What is the most important reason you are attending a virtual workshop at Jake's House? *

Expand my skills Opportunity to meet new people and socialize Provide parents/caregivers with an opportunity to get a break or do other things in the day Other
Have you attended another Jake's House workshop? *

Yes No
If so, please list the workshops you enjoyed the most.

Culinary Minecraft Science Craft Dance Employment Skills Jake's Hangout Performing Arts
TORONTO MARLIES SUITE GIVEAWAY

Refer a Friend to our Legends Mentoring Program workshops for a chance to win Toronto Marlies Suite tickets! You and your referral could win three tickets each!

Takes place March 23rd 7:00 pm at Coca-Cola Coliseum.

Contest Rules:

1. Yourself registering for any workshop.

2. Referring a friend to register in this form (friend must register and have never attended Jake's House workshops before)

3. The more referral names, the more chances to win! One entry= Your name + Referral Name

4. No duplicate names

4. Two different sets of winners (one set= one registration + referral registration)

4. Contest ends March 17th
I would like to enter and refer a friend(s) I have been referred I don't want to enter
How many people do you want to refer? (Remember the more referrals, the more entries!)
Referral Name 1

First Name Last Name
Referral Name 2

First Name Last Name
What was the person's name that referred you?

First Name Last Name
Referral Name 3

First Name Last Name
Is there anything else you would like us to know, or would you like to share any workshop ideas you hope to see in the future?
If you haven't already, do you want to join our mailing list to keep up with all Jake's House events & activities?

Yes, subscribe me to this newsletter.
*

I have read and agree to Jake's House "Terms of Service".
Jake's House Terms of Service - Click HERE
Should be Empty:

Jake's House Virtual Dance Workshop

TORONTO MARLIES SUITE GIVEAWAY