Participant Profile Form

Participant Profile -
Please complete for both your child and any sibling. Separate forms for each.

Name *

First

Last

Name(s) of Parents *

Select One *

Age *

Email *

Cell Phone: *

Who should we contact in case of emergency (supply name and cell phone number) *

Special Needs (Specific Conditions and Challenges *

Does your child know his/her diagnosis? *

Yes No

What do you hope to gain from your child's experience with Spectrum Therapeutic Theatre? *

Top Three SOcial Issues for your Child? *

Please describe any issues you feel would be helpful for staff to know regarding your child's conditions *

What are your child's interests and strengths? *

I give permission to take video/photos of my child during class which may appear on website (pictures will be made available to families at no charge) *

Yes No

Submit

Participant Profile - Please complete for both your child and any sibling. Separate forms for each.

Participant Profile -
Please complete for both your child and any sibling. Separate forms for each.