ATTENDEE Name *

First Name

Last Name

ATTENDEE Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

ATTENDEE Date of Birth *

MM

DD

YYYY

GUARDIAN Name *

First Name

Last Name

GUARDIAN Relation to Attendee *

Mother

Father

Grandmother

Grandfather

Other

GUARDIAN Cell Phone *

(###)

###

####

GUARDIAN Address (If different from Attendee)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

ATTENDEE Diagnosis *

Check all that apply

None/Unknown

Autism Spectrum Disorder

Attentional Deficit Hyperactivity Disorder

Down's syndrome

Cerebral palsy

Brain injury

Learning disability (i.e. Dyslexia, Dysgraphia)

Other, please list below

ATTENDEE Communication Strategy *

At this time, The I'mPerfect Place is not able to support those with speaking differences who DO NOT have a reliable form of communication. In order to best support our Learners, differently or nonspeaking applicants must have experience with and usage of communication devices/strategies. Please check all that apply.

Reliable speaker/verbal

Facilitated Communication

Rapid Prompt Method

Spell 2 Communicate

Choice Boards

Independent Typing

Other, please list below

ATTENDEE Physician's Name *

Please list primary care physician.

First Name

Last Name

Physician's Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

*

I certify that the above information is correct.