Inclusive Play to Learn Registration

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* 1. Please share your contact information.

First Name *

Last Name

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. If more than one adult will participate, even occasionally, please share their contact information.

First Name

Last Name

ZIP/Postal Code

Email Address

Phone Number

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* 3. Please share information for your child.

First Name *

Last Name *

Age *

Food allergies/aversions

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* 4. Please share information for your child.

First Name

Last Name

Age

Food allergies/aversions

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* 5. Please indicate your family's relationship, if any, to A Step Ahead in Pierce County.

My child currently receives services from A Step Ahead Pierce County

My child is not currently but has received services from A Step Ahead Pierce County in the past

My child receives services from another organization

My child does not receive any services

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* 6. Is there anything else you'd like us to know about your child?

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* 7. CLASS COMMITMENT: I understand participation is free of charge and voluntary. I am aware that by committing to participate, I am filling a slot that could be used by another family. Accordingly, I will strive to attend each of the nine weeks, and to participate to the best of my ability. Please indicate your agreement by typing your name in the box below.

I agree to this commitment