PACER FUN TIMES--Participant Interest Form

Thank you for your interest in PACER FUN TIMES program. Please complete this form and submit it. If you have questions, please contact PACER FUN TIMES coordinator danna.mirviss@pacer.org.

Question Title

* 1. Please enter information about the PARTICIPANT. All boxes must have an answer. If the question does not apply to the participant, enter NA.

Participant's full name

Participant's address

Participant's city

Participant's State, zip code

Cell phone number

Email address

School

Participant's age

Question Title

* 2. CONTACT PERSON #1
Please enter information about the participant's parent, guardian, or emergency contact person. All boxes must have an answer. If any information is the same as the participant's, enter SAME AS ABOVE. If not applicable, enter NA.

Full name

Relationship to participant

Address

City, state, zip code

Cell phone number

Alternate phone number

Email address

Question Title

* 3. CONTACT PERSON #2
Please enter information about the participant's other parent, guardian, or emergency contact person. If any information is the same as the participant's, enter SAME AS ABOVE. If not applicable, enter NA.

Full name

Relationship to participant

Address

City, state, zip code

Cell phone number

Alternate phone number

Email address

Question Title

* 4. Does the participant have a disability, Y or N?

Question Title

* 5. Does the participant need any accommodations to participate in FUN TIMES activities, or is there information you want PACER to know?

Question Title

* 6. Why does the participant want to be involved in FUN TIMES?

Question Title

* 7. List activities that the participant thinks would be fun and interesting.

Thank you for filling out this interest form. PACER's FUN TIMES coordinator, Danna Mirviss, will be in touch with you about the upcoming activities. Please click SUBMIT to send in your form.

PACER FUN TIMES--Participant Interest Form

Question Title

Question Title

* 1. Please enter information about the PARTICIPANT. All boxes must have an answer. If the question does not apply to the participant, enter NA.

Question Title

* 2. CONTACT PERSON #1Please enter information about the participant's parent, guardian, or emergency contact person. All boxes must have an answer. If any information is the same as the participant's, enter SAME AS ABOVE. If not applicable, enter NA.

Question Title

* 3. CONTACT PERSON #2Please enter information about the participant's other parent, guardian, or emergency contact person. If any information is the same as the participant's, enter SAME AS ABOVE. If not applicable, enter NA.

Question Title

* 4. Does the participant have a disability, Y or N?

Question Title

* 5. Does the participant need any accommodations to participate in FUN TIMES activities, or is there information you want PACER to know?

Question Title

* 6. Why does the participant want to be involved in FUN TIMES?

Question Title

* 7. List activities that the participant thinks would be fun and interesting.

* 2. CONTACT PERSON #1
Please enter information about the participant's parent, guardian, or emergency contact person. All boxes must have an answer. If any information is the same as the participant's, enter SAME AS ABOVE. If not applicable, enter NA.

* 3. CONTACT PERSON #2
Please enter information about the participant's other parent, guardian, or emergency contact person. If any information is the same as the participant's, enter SAME AS ABOVE. If not applicable, enter NA.