Name of Registering Adult (Participant #1) *

First Name

Last Name

Cell Phone Number *

(###)

###

####

Name *

First Name

Last Name

Name

First Name

Last Name

Name

First Name

Last Name

Which of the following applies to you and/or a family member? *

Please mark all that apply. There is a space after this question where you can provide additional information.

Environmental / Food Allergies

Severe Anxiety / Panic Attacks

Aggressive tendencies towards other people or animals

Vision and/or hearing deficit that will require special accommodation

Mobility issues that will require special accommodation

Other

None of the above

This program will be held outdoors and we should dress appropriately for the weather. *

No

Yes

Every participant must wear closed-toe shoes at all times. *

No

Yes

This is a mindfulness and stress reduction program and is NOT therapy. *

No

Yes

Every participant must wear a mask at all times, even outdoors. *

No

Yes