Limitless, Lawrence Co. "Plentiful Picnic"

Question Title

* 1. Participant's Full Name

Question Title

* 2. Participant's Age

Question Title

* 3. Guardian's Full Name

Question Title

* 4. How many people, excluding the participant, are attending the event?

Question Title

* 5. Please specify the participant's diagnosis.

Question Title

* 6. Please indicate any allergies or food restrictions the participant has. Select all that apply.

Peanuts

Tree Nuts

Dairy

Gluten

Soy

Egg

Shellfish

Food Dyes

Other (please specify)

None

Question Title

* 7. Please describe any behavioral tendencies of the participant that we should be aware of.

Question Title

* 8. Guardian's Email Address

Question Title

* 9. Guardian's Contact Number

Question Title

* 10. I consent to my image, video, and audio being captured and used by Limitless, Lawrence Co., for promotional materials, social media, livestreams, and other related purposes. I understand that if I select “No,” efforts will be made to avoid featuring me, but complete exclusion from group photos or videos may not always be possible.

Yes

No