A Place for Me Registration

A Place for Me Registration
Individual with Down syndrome

First NameLast Name
Birthdate

MonthDayYear
Date
Gender
Race/Ethnicity (check all that apply)

American Indian/American NativeAsian/PIBlackHispanicWhiteUnknown
Primary/Secondary Language
3 words to describe this individual
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Contact Phone Number
Please enter a valid phone number.
Family Contact Email
example@example.com
Parent 1 Name and Preferred Pronouns
Parent 2 Name and Preferred Pronouns
All siblings names, preferred pronouns and birthdates
Allergies
Preferred Accommodations
Annual Income (optional)

$0-$50K$50K - $75K$75K - $100K$100K - $250K$250K+
Religious Preference (optional)
By submitting this registration I hereby waive all claims against 321 Buddy Fundraising, sponsors, vendors, volunteers and any personnel for any injury that I, or my family members, might suffer while participating in activities at A Place for Me. In addition, I recognize my responsibility to provide full supervision to all children and dependents I bring to this location.
I also grant full permission for organizers to use photographs, videos, and quotations of myself, and my family members, in legitimate social media accounts, the organization website (321Buddy.org) and promotions of future 321 Buddy events. Please note that 321 Buddy commits to screening all pictures and videos to ensure they are appropriate and reflect participation in a positive light.
Additional Comments
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