Autism Awareness Clinic

Attention: Registration is now closed. Sign up to be put on the waiting list.

Parent or Guardian's Name*

First Name

Last Name

Relationship to Participant*

Participant's Name*

First Name

Last Name

Nickname

What age is the participant?*

What grade level is the participant?*

What type of setting do you work well in?*

Have you participated in sports before?*

Shirt Size*

Email*

Phone*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Please feel free to share any additional information about your child, that you feel would be helpful below

Please tell us how you heard about this event.*

Have you or a family member participated in this clinic before?*

Yes No

If yes, how was your experience and what would you change to positively impact your experience?

If you do not receive a call or forms in the mail in 2 weeks, please call us at 267-479-1148