A rainbow-colored Pride card for autism awareness on a wooden table with blue and white pamphlets, and other small cards, with a colorful shirt and a person's arm resting on their face in the background.

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Interested in joining into all the fun? Register for an activity you’d like to attend!

Child Information

Child's Name

First Name

Last Name

Date of Birth

YYYY

Age

Gender

Diagnosis (if any)

Primary Language Spoken

Parental Information

Parent Name

First Name

Last Name

Relationship with Child

Phone

(###)

###

####

Mailing Address

Program You Are Registering For (select one)

Sensory Learn and Play

The Gentle Diner Sensory Dining Experience

Medical and Emergency Information

Primary Care Physician Name

First Name

Last Name

Phone

(###)

###

####

Allergies or Medical Conditions

Medications (if any)

Emergency Contact Information

Emergency Contact Name

First Name

Last Name

Relationship

Phone

(###)

###

####

Permissions & Agreements

Photo/Video Consent

I give permission for my child to be photographed or video-recorded for educational/promotional purposes.

I do not give permission.

Liability Waiver & Consent for Participation

I understand and agree that I am enrolling my child in a therapeutic or recreational program run by the DiVittorio Center for Autism. I consent to participation and release the center from liability in case of injury.

Conclusion

Signature of Parent/Guardian (Digital)

Current Date

YYYY

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Location

Contact

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