Vintage Buddies Website Registration

1
Child's Name* This field is required.
First Name
Last Name
2
Child's date of birth* This field is required.
3
Child's grade* This field is required.
4
What would you like us to know about your child's diagnosis?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
5
Would your child benefit from a buddy to stay with them for the entirety of the service?* This field is required.
YESNO
6
Preferred Service* This field is required.
Please Select
Please Select
8:15am
9:45am
11:30am
7
Emergency Contact* This field is required.
8
Phone Number to reach during service?* This field is required.
Please enter a valid phone number.
9
Will your child need assistance using the restroom?* This field is required.
YESNO
10
Anything else you would like us to know?
Huge
Large
Normal
Small
Ok
Ok
11
What date/time are you planning your first visit to VG?* This field is required.
Should be Empty: