Keep Calm Sensory Zone PlayPass Request Form
CLTS: Use this form to purchase play pass packages for your client (child/family).
Name of client (child)
*
First Name
Last Name
Child's date of birth
*
What is the client's (child's) medicad/medicare number? * If billing using CLTS funds please provide the medicad number. The # is not mandatory when using CCOP funds.
Parent/Guardian's Name
*
First Name
Last Name
Parent/Guardian's Email
*
example@example.com
Parent/Guardian's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address of the family
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What county does the family live in?
*
Case Manager's contact information
Case Manager's Name
*
First Name
Last Name
Case Manager's Email
*
example@example.com
Case Manager's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please share with us the play options the family would like to obtain. If you want to purchase fidgets, fidget purchases are requested in a different form.
How many PlayPasses would you like to purchase for the client (family). PlayPasses DO NOT expire. You can submit this form for passes for each client more than once throughout the year (as approved by your organization).
6 Play passes = $100
12 play passes = $200
16 play passes = $275
20 play passes = $340
1 time play to check the Sensory Zone out = $20
Unlimited Play Monthly PlayPass (for counties that approve it through CLTS, billed monthly.)
If you select the monthly unlimited PlayPass, how many children in the family will be using the PlayPass? 1, 2, or 3+ children (1 = $100, 2 = $150, 3+ = $200 monthly).
How would you like to pay for the PlayPasses purchased for the client (family).
*
Contact me for a Credit Card
Send me an invoice (CCOP, CLTS)
Bill Gainwell (Does not apply to Dane County)
Submit
Should be Empty: