Membership and Waiver Form

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We are so glad you’ve decided to sign up and hope you find our space welcoming. We are a proud community of disability. We welcome families with children with any type of disability, be it visible, or not, diagnosed, or not. We are a space where disability is celebrated.

Everyone who comes into our spaces is considered a member. For funding purposes and so we are able to see who we are serving, we ask that you fill out the following information. Please know that this information is kept confidential and names attached to the below information are never shared, nor discussed internally or externally.

Email *

Family Information

Caregiver's First Name *

Caregiver's Last Name *

Phone *

Email *

Number of children living in the household: *

Number of adults living in the household: *

Is your household income below $25,000 annually? *

Yes

Does your family/child qualify for:

Check all that apply *

In school free lunch

Medicaid Waiver

SNAP

Medicaid

None of the above

Required

Family Composition

Please select one. *

Single, never married

Divorced or separated

Widowed

Married or domestic partnership

Child not living with parents (foster home)

Child not living with parents (family member)

Other

If you selected 'Other' above, please specify here:

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