Sibshops Application Tell Us About the Child You'd Like to EnrollChild's Name* First Middle Last Birth Date* MM DD YYYY Age*Gender*MaleFemaleSchool*Grade*SecondThirdFourthFifthSixthSeventhEighthTell Us About YouMother's Name First Last Father's Name First Last Home Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Cell Phone*Emergency ContactEmergency (alternate) Contact Name* First Last PhoneTell Us About The Brother or Sister with Special NeedsName* First Last Birth Date* MM DD YYYY Age*Gender*MaleFemaleSchool*Grade*Pre-KindergartenKindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfthName or description of disability, diagnosis, or health concernRelated ServicesWhat kind of related special education services (e.g., speech, occupational or physical therapy, counseling, chemotherapy, etc.) does this child receive? Include date of diagnosis and other important details.Tell Us About Their Other SiblingsHow many other siblings besides these two?012345Name First Last AgeGenderMaleFemaleName First Last AgeGenderMaleFemaleName First Last AgeGenderMaleFemaleName First Last AgeGenderMaleFemaleName First Last AgeGenderMaleFemaleTell Us Additional InformationWhat do you hope your child will gain from our Sibshop*? Are there any particular topics you would like addressed?Does your enrolled child have any special needs, food allergies, or other health restrictions of their own that we should know about?Please provide any other information that you feel would make Sibshops a more enjoyable and educational experience for your child.Would you like your name placed on a list to be distributed to siblings and their families?YesNoWould you like your phone number included?YesNoCommentsAuthorization (form cannot be submitted without this)*I hereby give my child permission to participate in Sibshops. I also agree to hold Project Joy and Hope harmless for any and all liability incurred as a result of my child’s participation. Further, I grant full permission to use any photographs, videotapes, recordings or any other record of this program for the purpose of education and promotion of Sibshops. Yes Signature*Please sign in this box with your mouse, trackpad or screen.Date* Date Format: MM slash DD slash YYYY Our staff will call you upon receipt of this completed form to go over final details, answer any additional questions you may have, and provide directions to the Sibshop. Sibshop Dates: Second Saturdays monthly Sept. 8, Oct. 13, Nov. 10, Dec. 8, Jan. 12. Feb. 9, Mar. 9, April 13, May 11 Summer Camp Dates: June 12, 13, 14, 2019 (free) 3219 Burke Road, Pasadena, TX 77504 *Sibshop and Sibshops are service marks and trademarks owned by Donald J. Meyer on behalf of the Sibling Support Project. Sibshops Workshops for Siblings of Children with Special Needs, Revised Edition, by Don Meyer and Patricia Vadasy. Copyright©2008. Paul H. Brookes Publishing Co. All rights reserved. This iframe contains the logic required to handle Ajax powered Gravity Forms.