Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

Gender

Age

Phone

(###)

###

####

Email

Preferred Mode of Communication (Email, Phone or Text)

Guardian's Name

First Name

Last Name

Guardian's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Relationship to Participant

Guardian's Email

Guardian's Phone

(###)

###

####

Preferred Mode of Communication (Email, Phone or Text)

Is Participant Regional Center Client?

If Yes, List Name

School Attending

Day Program Attending

Other......

List Favorite Activities and Preferences

Why are you interested in The Miracle Project?

If participants is not the person completing this form please state

Name

Relationship to Participant

How did you hear about us?