Reimagine Parent Support Group Registration Form
One form per CHILD please
Child's Name
First Name
Last Name
Age
Does your child can go to the bathroom without help?
Yes
No
Bathroom assistance?
Need assistance all the time
Assistance only if needed
Zero Bathroom assistance
Any known allergies?
Other medical conditions?
Fears and dislikes?
Can he/she follow simple instructions?
Yes
No
What instructions can he/she follow?
Verbal
Written
Gestures
Picture (Visual aid)
Other
Does your child need feeding instructions/restrictions/special diet?
Yes
No
If yes, please provide us with detailed explanation
Is he/she aggressive?
Yes
No
Do you have any behavioral plan or instructions?
Parent/ Caregiver Attending Information
Parent/ Caregiver (1)
First Name
Last Name
Parent/ Caregiver (2)
First Name
Last Name
Main Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Submit
Should be Empty: