Community Event Registration
Mosaic Minds creates sensory-friendly, educational, creative and community-based experiences designed to help neurodivergent individuals learn, connect, explore and enjoy new experiences. Please fill out the information below to register or get more information on upcoming community events. We will provide you with the appropriate details following the submission of the form.
Contact Information
Participant Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Text
Call
Relationship to Participant
*
Self
Parent
Guardian
Caregiver/Support Person
Service Coordinator
Other
Funding
*
Alta California Regional Center
SDP
Private Pay
Charter/Homeschool Funds
Not Sure
Other
If you selected Alta California Regional Center, please enter your Service Coordinator's name and email. Please also state if you would like information to sent to your service coordinator for authorization.
Participant Information
Participant Name
*
First Name
Last Name
Participant Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age Group of Participant
*
Children
Pre-Teen
Teen
Young Adult
Adult
Select Event(s) You Are Registering For:
*
Not-So-Spooky Fall Festival - October 17th
Family STEM Build & Play Day - November 21st
Sensory-Friendly Winter Wonderland - December 19th
Glow, Move & Explore Sensory Night - January 23rd
Please select one option:
*
Please Select
Register
Request More Information
How did you hear about us?
*
Instagram
Facebook
Family/Friend
Current Mosaic Minds Family
Employee
Community Event/Organization
Google Search
Other
What interested you about this event?
*
Anything else you would like us to know?
Would you like to receive Mosaic Minds program updates, events, announcements by email?
*
Yes
No
Do you consent to being photographed/recorded during the event for social media use?
*
Yes
No
Please verify that you are human
*
Submit
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