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Hearts & Connections Registration
Join us for a dual track event where both caregivers and children can develop skills and create connections through fun and play!
Registrant and Child Information
Caregiver Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Child's Name
First Name
Middle Name
Last Name
Child's Age
Additional Children
Child's Name
First Name
Last Name
Child's Age
Child's Name
First Name
Last Name
Child's Age
Child's Name
First Name
Last Name
Child's Age
Child's Name
First Name
Last Name
Child's Age
Additional Children
Participation and Accessibility Details
Which track(s) will you join?
Roots & Wings (children's program)
Rooted in Care (caregiver workshop)
Both
Mobility considerations
Wheelchair user
Uses a walker or mobility aid
Needs clear/wide pathways
No accommodations needed
Other
Mobility considerations - other (please describe)
Communication style
Verbal
Uses AAC device
Uses sign language
Uses picture cards / visual supports
Other
Communication style - other (please describe)
Sensory considerations
Anything else that would help your child fully participate?
Allergies
Medical conditions our staff should be aware of
Emergency and Pickup Information
Emergency Contact Full Name
First Name
Last Name
Authorized Pickup Full Name
First Name
Last Name
Arrival, Consent, and Follow-up
Photo/video consent
*
Yes, OCL may use photos/video from this event for marketing
No, please do not photograph my family
How did you hear about us?
ARC of Loudoun / Ally Center
L-Lab
We Rock the Spectrum
Community Foundation
Social media
Other
How did you hear about us? - other (please describe)
Open to a short follow-up survey after the event?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Suggested Admission: $15/family. Pay what feels right for you! Every amount helps us keep Hearts and Connections accessible
$15 (suggested minimum)
$25
$50
Other
Number of Children Attending
*
Calculation
Payment Amount
*
prev
next
( X )
USD
Description
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
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