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Free Fun Fishing Derby • Saturday June 7th 2008 • 9:00am-1:00pm
Lake Cherrywood Park, Sherwood

REGISTRATION FORM

Name

Address

Phone number

Email address


Number of adults attending

Relationship to child(ren)


Number of children attending

Name, sex, and disorder of each child:
Child name Age Sex Disorder
Child name Age Sex Disorder
Child name Age Sex Disorder
Child name Age Sex Disorder
Child name Age Sex Disorder

If Neither, relationship to child with disorder


Does your child have any allergies, food requirements, special attention, etc. that we need to be aware of? Yes No
If yes, please explain:

Would you like to be contacted for upcoming events pertaining to your child's disorder? Yes No

Would you like to become a free member of PEACE? Yes No

Do you need additional training, information, materials, resources, help, etc regarding your child and his/her disorder? Yes No



Once you've completed the form and submitted, we will email you about your registration verification.

 

Any questions please contact Mandy Ochoa, 501-563-5211