Gaming Club Registration Fall 2023 | Tater Tots Pediatric Therapy

Participant Information *

First

Last

Age *

Race/Ethnicity (Optional)

Other

Gender Identification (Optional)

Other

Does the Participant Have a Known Seizure Disorder? *

Pertinent Health Diagnoses *

Answer "none" if not applicable

Needed Adaptations for Participation *

Answer "none" if not applicable

Allergies *

Answer "none" if not applicable

Primary Contact *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Secondary Contact

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Other Persons Allowed to Pick Up or Drop Off

Optional Donation

Participation in gaming club is free, but donations are welcome, with all proceeds going back into the program.

Other

Photo and Video Release *

I acknowledge that photos and videos from this program can and will be used for informational and advertising materials. The use of photos and videos may include, but is not limited to, social media posts, posts on the organization's website, digital advertisements, news stories, and paper advertisements.

Signature *