Membership and Waiver Form
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 address *
Family Information
Caregiver's First Name *
Your answer
Caregiver's Last Name *
Your answer
Phone *
Your answer
Email *
Your answer
Number of children living in the household: *
Your answer
Number of adults living in the household: *
Your answer
Is your household income below $25,000 annually? *
Does your family/child qualify for:
Check all that apply *
Family Composition
Please select one. *
If you selected 'Other' above, please specify here:
Your answer
Never submit passwords through Google Forms.
This form was created inside of Extreme Kids & Crew. Report Abuse - Terms of Service