Sibshop Registration-Health-Consent Form

Registration-Health-Consent Form

If enrolling more than one child, complete separate forms for each child. This form applies to your child for the year 2025, for Sibshops and SibDays of Summer. If any information changes, please notify us, tessa@wisconsibs.org or 920-393-733.
Participant information
Today’s Date

MonthDayYear
Date
Region*
Child's Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Gender

MaleFemalePrefer not to sayOther
T-shirt Size
Does this child receive any special services (counseling, speech/language therapy, special education)?

YesNo
If yes, please describe:
Child school and city:
Has this child attended Sibshops in the past? If so, where?

Tell us about their sibling:

Please provide the following information on their sibling with disablities, other siblings, information on their relationship and interest in Sibshops.
Sibling with Disability*

First NameLast Name
Birthdate*

MonthDayYear
Date
Gender

MaleFemalePrefer not to say
Diagnosis or Nature of Disability*
How would you describe the relationshiop between this child and the sibling attending Sibshops currently? (close, distant, loving, tolerant, frustrating, involved, uninvolved, etc?)
Other Siblings in the family: (Name, birthdate, gender)
What are your reasons for enrolling your child in the Sibshop program?
Do you have any concerns about enrolling your child in Sibshops?
Please provide any other information that you feel will make this an enjoyable and valuable expereince for your child. Include any fears, concerns, food strongly disliked, favorite activities, favorite foods:

PERMISSION FORM – all children must have this completed.
Child’s Full Name
I understand that in case of serious injury or illness, the person that I identified as the emergency contact will be notified, but if it is impossible to contact us, we give permission for emergency treatment or surgery as recommended by the attending physician.
Name*

First NameLast Name
Emergency Phone*
Relationship to Child
MEDICAL INFORMATION FOR CHILD ATTENDING SIBSHOP OR SIB DAYS
In the case that medical information is required, the following information must be available.
Child’s Physician*
Physician Phone*
Insurance Provider*
List any FOOD allergies or diet restrictions:*
I understand that in case of injury or illness, I do hereby waive all claims or legal actions, financial or otherwise, against WisconSibs, Inc., the organizers, sponsors, supervisors or any volunteer connected with the program.*

Yes, I understand and give permissionNo, I do not give permissions and will not be enrolling in this program
Parent/Guardian Signature*

Clear
PHOTO PERMISSION
I grant full permission to use any photographs, videos, or recordings or any other record of this program for the purpose of community education and awareness. A child’s full name will not appear on the WisconSibs website or Facebook page, even if you sign the form*

Yes, I give permissionNo, I do not give permission
Parent/Guardian Signature

Clear
Should be Empty:

Registration-Health-Consent Form