Parent Support Group Registration Form
Special Guest speaker Kim B Wells M.ED, BC-ABA, LBS
The ABCs of ABA- Training Overview
Date: October 28th, 2025 5:30pm-7:00pm
Parent/ Guardian Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Phone Number
*
Preferred Contact Method
Phone Call
Text
Email
Would you like a link to attend virtually?
Yes
No
Additional Comments
PERMISSION TO PHOTOGRAPH OR VIDEOTAP
I give permission to be photographed or recorded on video. I understand that these photos or videos may be used by JAFCO to promote its mission, raise awareness, and support fundraising efforts. This may include use in flyers, fundraising materials, and on JAFCO’s social media accounts.
Yes, I consent
No, I do not consent
Date
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Month
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Day
Year
Date
Signature
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