Sibling Squad Registration

Child's First and Last Name*
Child's Age*
Child's Date of Birth*
Child's Gender*
- Male
- Female
Does this child receive any special services (e.g., counseling, speech therapy, special education)? If yes please explain.*
Mom's First and Last Name*
Mom's Cell Phone Number*
Dad's First and Last Name*
Dad's Cell Phone Number*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Name of Brother/Sister with Special Needs*
Age of Brother/Sister with Special Needs*
Nature of Disability*
What kind of related special education services (e.g., speech, occupational, or physical therapy, counseling, etc.) does this child receive?*
Does your child have a good understanding of their sibling's disability?*
Has your child ever attended a sibling workshop? If so, when and where?*
Why are you enrolling your child in the Sibling Squad program?*
Do you have any concerns about enrolling your child in Sibling Squad?*
Do you have any particular topic that you would like addressed?*
Does your child need to take any medications during the hours of Sibling Squad? If yes, please explain.*
Does your child have any food allergies or restrictions? If yes, please explain.*
Please provide any other information that you feel will make this an enjoyable and educational experience for your child.
I understand that to complete this registration, I must also go onto the Autism Society Central VA website and pay the Sibling Squad fee.*
Payment can be made at the bottom of this page --- https://ascv.org/meetings-events/siblingsquad
Comments
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