EVENT REGISTRATION

Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Birthday *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender *

Male

Female

Please indicate the individual's primary communication style. *

Check all that apply!

Verbal Speech

Gestures and vocalizations

Uses AAC device

ASL/ Sign language

Does the individual have a history of seizures? *

Yes

No

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Please indicate the level of support needed for the restroom. *

Check all that apply!

Tolieting

Wiping

Clothing management

Washing hands

Individual is independent and does not require additional support.

Please indicate the level of support needed for eating. *

Check all that apply!

Support to get food

Support to use utensils

Support for pacing while eating

Individual is independent and does not require additional support.

Please indicate the individual's level of mobility. *

Check all that apply!

Uses walker

Uses wheelchair

Uses power wheelchair

Needs assistance while walking

Independent while walking

Describe the requested level of support for JoyKC nights: *

We do our best to provide one-on-one volunteers for those who may benefit from this level of support and/ or engagement. But, you are the expert here. Tell us how we can BEST serve this individual.

One-on-one Buddy requested

Does not need or want one-on-one Buddy

If there's one available, great. If not, great!

I give JoyKC permission to use photographs of me for purposes including publicity, advertisement, illustration, social media, and web content. *

Yes

No

Please type your name to electronically sign this form. *

First Name

Last Name