Form

First/Last Name of Actor's Guardian (that's you!)*

Phone number

Email*

Actor's First Name*

Actor's Last Name*

Street address

City*

State/Region*

Emergency Phone Number

Please check if your actor IS aware of their diagnosis?

Actor's Date of birth*

Does your actor have any allergies?*

Please note that during break we offer sugar free icy-poles.

How does your actor like to be calmed?*

Does your actor have any fears we should be aware of?*

Actor's preferred pronouns*

Help us know how to to address your actor (he/him, she/her, they/them etc)

What school does your actor attend?*

Are there any potential obstacles to attending sessions?*

(i.e., actor finds it challenging to come to class, can feel overwhelmed by loud sounds, etc.)

What are some of your actor's key interests?*

(i.e., Minecraft, Lego, Drawing, Animals, Singing etc.)

How did you hear about us? *

(Who do we have to thank?)