Cache Valley Park Play Date

Participant Contact Information

• Please provide the following information as part of the registration. This information is needed to help us better serve you and to document our services for our funders. This information will be kept strictly confidential. Thank you.

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * ZIP Code:
• * Phone:

Participant Demographic Information

• *

  What is your role?

  • Parent
  • Other Family Member
  • Student
  • Professional
• *

  What is your race/ethnicity?

  • Caucasian
  • Hispanic
  • African American
  • Asian
  • Native American
  • Pacific Islander
  • Two or More Races
  • I choose not to disclose this information
• *

  What is your primary language?

  • English
  • Spanish
  • Other
• *

  Does your child qualify for:

  • Free Lunch
  • Reduced Fee Lunch
  • Neither

Child Demographic Information

• Please include your child's demographic information below, if you have more than one child please list the child you are primarily attending this event for. If you are a professional, please use NA or choose the "I am a professional" option.

• * Child's Name
• * Child's Date of Birth:
• * School District or Charter School Child Attends:
• *

  Child's Race/Ethnicity

  • Caucasian
  • Hispanic
  • African American
  • Asian
  • Native American
  • Pacific Islander
  • Two or More Races
  • I choose not to disclose this information
  • I am a professional - does not apply
• *

  Child's Primary Disability

  • Autism
  • Deaf-Blindness
  • Deaf-Hearing Impairment
  • Developmental Delay (Ages 0-8)
  • Emotional Disturbance
  • Intellectual Disability
  • Multiple Disabilities
  • Orthopedic Impairment
  • Other Health Impairment (ex. ADHD)
  • Specific Learning Disability
  • Speech/Language Impairment
  • Traumatic Brain Injury
  • Visual Impairment/Blindness
  • Suspected/Undiagnosed
  • I am a professional - does not apply
• * Child's Specific Disability
• *

  Child's Insurance:

  • Private
  • Medicaid
  • Medicaid Waiver
  • CHIP
  • None
  • I am a professional - does not apply
• *

  Services:

  • DSPD Services
  • DSPD Waitlist
  • Technology Dependent Waiver
  • Medically Complex Children's Waiver (MCCW)
  • None of the above
  • I am a professional - does not apply

Guest Information

You may add a maximum of 10