Instructions: This is the registration form. It is intended to gather information on the parent/guardian and the involved children. This form only needs to be filled out once. The contact email will be used to notify you of any events/activities, updates or changes. We look forward to having you be a part of Playdates Foundation Inc.!!

* Asterick means these fields are required

Parent or Guardian Information (only one individual's information is needed):

Prefix: Mr. Mrs. Miss Dr. Select a Prefix

First Name*: Middle Initial: Last Name*:

Contact Email Address*:

Address (optional):

City*: State*: Zip Code*:

Child/Children Information:

Child 1:
First Name: Middle Initial: Last Name:

Age: Gender: Select Gender... Female Male Contact Email Address:

Favorite TV Show:

Favorite Movie:

Favorite Color:

Activities / Hobbies:

Child's Disability Check one of the following:

High Function (Learning Disabilities, Mild Developmental Disorders, Partial Paralysis or Loss of Ligaments)

Medium Function

Low Function (Severe Autism, severe developmental disorders)

Allergies or other items that your child must stay clear of (i.e., excessive sun, severely low immune system, bright lights, etc.)

Does your child use any assistive devices (i.e., wheelchairs, crutches, etc.)?

Ready to Register...click the Register Button at the bottom of the screen. Scroll to Bottom of Form.
Not ready yet...have more kids to register, continue filling out the form.

Child 2:
First Name: Middle Initial: Last Name:

Age: Gender: Select Gender... Female Male Contact Email Address:

Favorite TV Show:

Favorite Movie:

Favorite Color:

Activities / Hobbies:

Child's Disability Check one of the following:

High Function (Learning Disabilities, Mild Developmental Disorders, Partial Paralysis or Loss of Ligaments)

Medium Function

Low Function (Severe Autism, Full body paralysis, severe developmental disorders)

Allergies or other items that your child must stay clear of (i.e., excessive sun, severely low immune system, bright lights, etc.)

Does your child use any assistive devices (i.e., wheelchairs, crutches, etc.)?

Child 3:
First Name: Middle Initial: Last Name:

Age: Gender: Select Gender... Female Male Contact Email Address:

Favorite TV Show:

Favorite Movie:

Favorite Color:

Activities / Hobbies:

Child's Disability Check one of the following:

High Function (Learning Disabilities, Mild Developmental Disorders, Partial Paralysis or Loss of Ligaments)

Medium Function

Low Function (Severe Autism, Full body paralysis, severe developmental disorders)

Allergies or other items that your child must stay clear of (i.e., excessive sun, severely low immune system, bright lights, etc.)

Does your child use any assistive devices (i.e., wheelchairs, crutches, etc.)?

Child 4:
First Name: Middle Initial: Last Name:

Age: Gender: Select Gender... Female Male Contact Email Address:

Favorite TV Show:

Favorite Movie:

Favorite Color:

Activities / Hobbies:

Child's Disability Check one of the following:

High Function (Learning Disabilities, Mild Developmental Disorders, Partial Paralysis or Loss of Ligaments)

Medium Function

Low Function (Severe Autism, Full body paralysis, severe developmental disorders)

Allergies or other items that your child must stay clear of (i.e., excessive sun, severely low immune system, bright lights, etc.)

Does your child use any assistive devices (i.e., wheelchairs, crutches, etc.)?