Participant's Name *

First Name

Last Name

Participant's Birth Date *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Caregiver 1 - Name *

First Name

Last Name

Parent/Caregiver 1 - Phone Number *

(###)

###

####

Parent/Caregiver 2 - Name

First Name

Last Name

Parent/Caregiver 2 - Phone Number

(###)

###

####

Pediatrician/Doctor's Office Number *

(###)

###

####

What forms of communication is your participant familiar with? *

Speech

Sign Language

PECS (Picture Exchange Communication System)

How did you hear about this performance? *

Friend

Family

Social Media

Email Blast

Returning Participant

Participant's School

Flyer

Other