Player Application Form

Participant's Name *

Participant's Phone number *

Date of Birth *

MM

/

DD

/

YYYY

Caregiver / Parent / Group Home Manager Name *

Caregiver / Parent / Group Home Manager Phone Number *

Participant's Address *

How did you hear about us? *

Do you have any special interests? *

Poetry

Dancing

Singing

Art

Acting

Musical Instruments

Other:

Other Information: Health, Medication, etc. as would prove helpful in the program. *