Clubhouse Registration
Join the club, we are so happy you are here.
Name
*
First Name
Last Name
Have you been here before?
*
Yes
No
Age Group
*
Please Select
Child (0-12)
Teen (13-17)
Young Adult (18-30)
Adult (31-59)
Older Adult (60+)
What is your zip code?
*
Are you here for a program, walk-in visit or to volunteer?
*
Program
Walk-In Visit
Volunteer
How many people are in your group?
1
2
3
4
5+
Please select the program you are attending
*
Sing Sign Dance
Musical Learning with Lanny
KPOP Dance Class
Family Drum Circle
Sunday Funday
Family Stories
Adaptive Art with Alpha
Adaptive Art with Devereux
Harmony For Independence Music Workshop
Harmony For Independence Music Program
MS Luncheon
SPI Dinner
Other
Please type the name of the program
*
Please type the name of the event
*
Do you have a disability?
*
Yes
No
Please elaborate as you feel comfortable
Do you have any accommodation needs?
*
Yes
No
Please elaborate as you feel comfortable
Are you a client of Tri-Counties Regional Center (TCRC)?
*
Yes
No
Unsure
Please type your name and your service coordinators name
*
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Tell Us More (Optional)
This section is optional. The information you choose to provide helps us better understand our community, improve accessibility, and may be used in aggregate for grant reporting. If you'd prefer not to answer these questions, simply scroll to the bottom and click Submit. Thank you!
Participant Information
Email
example@example.com
Would you like to join our newsletter?
Yes
No
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Female
Male
Non-binary
Prefer not to answer
Other
Emergency Contact & Safety Information
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Participant
Please Select
Parent/Guardian
Family Member
Caregiver
Friend
Other
Allergies or Medical Considerations
Additional Information
Household Income Level
Please Select
Less than $25,000
$25,000–$49,999
$50,000–$74,999
$75,000–$99,999
$100,000+
Prefer not to answer
Race/Ethnicity
American Indian/Native
Asian
Black or African American
Hispanic/Latino
Native Hawaiian or Pacific Islander
White
Other
Prefer not to answer
Primary Language Spoken
Please Select
English
Spanish
American Sign Language (ASL)
Mandarin Chinese
Cantonese
Vietnamese
Tagalog
Korean
Japanese
Arabic
Russian
Farsi (Persian)
Other
Prefer not to answer
Please specify language:
Submit
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