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 Choose Disorder Autism Epilepsy Neither
Child name Age Sex Disorder Choose Disorder Autism Epilepsy Neither
Child name Age Sex Disorder Choose Disorder Autism Epilepsy Neither
Child name Age Sex Disorder Choose Disorder Autism Epilepsy Neither
Child name Age Sex Disorder Choose Disorder Autism Epilepsy Neither

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