"Sibshop" Child/Teen Application
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Email *
Date Of Application *
Child or Teen's Name *
Age *
Gender of Child *
Current Grade Level *
Name of Current School and School District *
Name of their Sibling's Disability Type *
Parent's Names *
Street Address *
City, STATE, ZIP Code *
Home Phone
Best Phone Number to reach Parent during Sibshop Group *
Availability for Participation in a SibShop: *
What type of Sibshop are you interested in participating in? *
What are your child’s favorite games, activities, hobbies or interests? *
What sorts of games, activities and themes are difficult or non-preferred for your child to engage in? *
Please describe the current relationship between your child and their sibling with special needs? *
Does your child know the specific name of their sibling’s diagnosis? *
What would you like your child or teen to get out of their Sibshop group experience? *
Please provide any additional information that would help us best support your child in their Sibshop experience! *
Medical Conditions
Please list any Medical Conditions and Medications that your child is currently treated by
Allergies and Food Preferences
Depending on the Sibshop session selected, a snack may be provided to your child.  You will have the option to send in your own snack if you prefer to meet your child’s dietary restrictions.  

Please list any and all environmental and food allergies.  Also please list any highly preferred foods, snacks & drinks and non-preferred foods, snacks & drinks. *
Person to Notify in Case of Emergency, Name and Relationship to Child: *
Best Phone Number *
Best E-Mail Address *
Our Policy
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. Our Directors will contact you as soon as a Viable Group has availability and we can match your individual needs accordingly.  This may take some time to find the best fit and groups are currently formed on an ongoing basis.  If you would like referrals to other Sibshops in your area, please visit www.siblingsupport.org

Agreement and Signature
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if my child is matched to an appropriate Sibshop, any false statements, omissions, or other misrepresentations made by me on this application may result in immediate dismissal from that group session.  

Sibshop groups in-person involve active, running and jumping games.  Parents will not hold Our Village liable for any play injuries or group accidents.

In addition, photos and/or videos may be taken of your child participating in our groups!  These photos/videos will be utilized on the Social Media or Website for OUR VILLAGE to help spread the word on our programs to families in our community. They may also be utilized in training professionals to run future Sibshops for more siblings in their communities.

Also, if your child shows any behaviors that are overly challenging such as aggression, rude verbalizations to others, running away from group, separation anxiety or hiding/shut down the majority of the time, Our Village staff will contact the parent/caregiver for support, collaboration and possible deferral of current group participation until another group later in the future.

Consent to utilize group photos of Sibshops for social media, website and trainings: *
If participating in a Virtual Group, please sign here to consent for virtual, telehealth support: *
Parent Name (Print to Affirm your consent to participate in our Sibshop Group with your Electronic Signature) *
A copy of your responses will be emailed to the address you provided.
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