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Fall Youth/Teen Registration
Fall Youth/Teen Registration
Fall 2019 Youth Registration Form
Participant First Name:
(required)
Participant Middle Initial:
Participant Last Name:
(required)
Participant Date of Birth:
(required)
Will anyone accompany this participant during RADD activities?
Yes
No
If yes, please explain:
Will a Service Animal accompany this participant during RADD activities?
Yes
No
If yes, please explain:
Participant Phone (If applicable):
Contact:
Parent
Guardian
Self
Group Home Manager
Other
Name of Group Home:
Contact First Name:
(required)
Contact Last Name:
(required)
Address:
(required)
City:
(required)
Zip Code:
(required)
Phone 1:
(required)
Phone 2:
Email:
(valid email required)
Prefer Contact by
Email
Phone
Party Responsible for Payment
Parent
Guardian
Agency
Self Pay
Other
Name of Agency:
Agency Contact Name:
(required)
Consultant Phone Number:
Consultant Email:
(required)
Youth Overnight Respites:
September 6th-7th $295.00
October 4th -5th $295.00
November 1st -2nd $295.00
December 6th -7th $295.00
48 hr CANCELLATION is required for all respites otherwise you will be responsible for payment
Kids Swim and Zumba
$140.00 7 Sessions
48 hr CANCELLATION is required for all respites otherwise you will be responsible for payment
Six Hour Youth Day Respites
September 28, 2019 $90.00
October 24, 2019 $90.00
October 25, 2019 $90.00
November 8, 2019 $90.00
November 23, 2019 $90.00
48 hr CANCELLATION is required for all respites otherwise you will be responsible for payment
Christmas Party December 15th 12 to 3 ||
Free
Agency Total $
Parent/Self Pay Total $
Comments:
Check here to have a copy of this Fall Registration forwarded to the email you provided above.
