Porch Play Registration
Please fill out all sections of the form below.

Participants are those for whom the Porch Play is created.
Present Caregivers are the adults who will be engaging in the program alongside the participant. 

Upon receipt, Pink Umbrella will reach out to you to schedule your 45-minute session! 
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Who is filling out the form? Please provide your name, relationship to the Participant(s), and contact information (email address and/or phone number).  *
Participant Name(s), Pronoun(s), and Age(s) *
Present Caregiver Name(s), Pronoun(s), and Relationship(s) to the Participant *
Present Caregiver Relationship(s) to the Participant *
Where would you like to hold the Porch Play: outside of your home (yard or porch), inside of your home, or public/community space?  *
What are the Participant's strengths? *
Are there any areas that you'd like the participant to grow in?  *
What access needs are required to support the Participant? Examples may include ASL, mindfulness of volume levels, etc.  *
Does the Participant wander or have a diagnosis that could cause a medical emergency or harm? *
Do the Participant and/or Present Caregivers have any food allergies or restrictions? If yes, please list all.
 *
How can we best communicate with all Participants and Present Caregivers? *
Topics, language, behaviors that trigger/aggravate the Participant(s) are... *
Please describe your household's COVID/social distancing preferences.  *
Which book(s) would be of interest to the Participant(s)?  *
Required
Which day(s) would be best for scheduling your program?  *
Required
Which time(s) would be best for scheduling your program?  *
Required
Anything else you'd like to share with Pink Umbrella before the program?  *
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