KAS Social Group Registration
Online tracking form for Adults with Autism who are attending KaleidAScope's Virtual AND/OR In Person Social Group
What is your FIRST and LAST name? *
What is your birthday? *
MM
/
DD
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YYYY
What is your PHONE NUMBER (with the area code)? *
Do you text message with that phone number? *
Can KAS staff text message you about group at that phone number? *
What is your email address? (make sure you check your spelling)
What is your FULL mailing address? (the place where you get mail). Include the STREET, CITY, STATE, and ZIP CODE
Please include the FIRST and LAST name of an emergency contact person. (this would be a person we could contact in the case of an emergency during group) *
Please list the PHONE NUMBER of your EMERGENCY CONTACT person (with area code). *
Do you give KAS permission to use your picture and/or video in marketing and public relation materials? *
How do you attend/will you attend social group?
Clear selection
Is there anything else we should know about you?
Submit
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