Participant Name *

First Name

Last Name

Name of Parent / Guardian (for participants who are minors)

Complete this field only IF participant is under 18 years of age.

First Name

Last Name

Cell Phone Number *

(###)

###

####

Which of the following applies to you (or your child)? *

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 participants should dress appropriately for the weather. *

No

Yes

Participants must wear closed-toe shoes at all times. *

No

Yes

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

No

Yes

Participants must wear a mask at all times, even when outdoors. *

No

Yes