Program Registration Form
Thank you for your interest in registering for services at EveryStep: Amanda the Panda. The following pages will provide us with the information needed to enroll you and/or other participants for our programming. Please allow 10-20 minutes to fill out the following forms. Participants must be in Kindergarten to be eligible for services (adults are eligible regardless of age).

We require a refundable deposit of $35 per person up to $100 maximum per family. This deposit will need to be mailed or dropped off to our office at 1821 Grand Ave, West Des Moines, IA 50265 before your registration will be finalized.

Your deposit will be cashed if: you do not let us know you are unable to attend or you cancel your attendance to support group or camp within a week of the event start date without a valid reason. NOTE: if you are unable to come due to death, illness, or other uncontrollable circumstances, your deposit will not be cashed.

If you have a financial hardship that would prevent you from registering for our services, please call our office at 515-223-4847 to discuss other options for finalizing your enrollment.

Primary Family Contact Information
Please provide the contact information for main family member registering for service. Please include your information even if you are not planning to attend services, but are registering on behalf of a child or minor.
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Employer
Your answer
Cell Phone Number *
Your answer
Home Phone Number
Your answer
Work Phone Number
Your answer
Email Address *
Your answer
Emergency Contact - Name, relationship to you, phone number *
Your answer
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