Sibling Squad Registration Sibling Squad Registration Child's First and Last Name* Child's Age*789101112Child'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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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.*YesPayment can be made at the bottom of this page --- https://ascv.org/meetings-events/siblingsquadNameThis field is for validation purposes and should be left unchanged.
