Inclusive Play to Learn Registration

Question Title

* 1. Please share your contact information.

First Name *

Last Name

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 2. If more than one adult will participate, even occasionally, please share their contact information.

First Name

Last Name

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 3. Please share information for your child.

First Name *

Last Name *

Age *

Food allergies/aversions

Question Title

* 4. Please share information for your accompanying child. Siblings are welcome to participate in the program. It's important for us to be aware of all children attending to be aware of space capacity.

First Name

Last Name

Age

Food allergies/aversions

Question Title

* 5. Please indicate your family's relationship, if any, to A Step Ahead in Pierce County.

My child currently receives services from A Step Ahead Pierce County

My child is not currently but has received services from A Step Ahead Pierce County in the past

My child receives services from another organization

My child does not receive any services

Question Title

* 6. Is there anything else you'd like us to know about your child?

Question Title

* 7. CLASS COMMITMENT: I understand participation is free of charge and voluntary. I am aware that by committing to participate, I am filling a slot that could be used by another family. Accordingly, I will strive to attend each of the nine weeks, and to participate to the best of my ability. Please indicate your agreement by typing your name in the box below.

I agree to this commitment