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Supporting Families with Special Needs
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F.U.N. Family Registration
Please complete the form below
Today's Date
*
MM
DD
YYYY
Name, Age and Birthdays of all Family Members
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone (Primary)
*
(###)
###
####
Phone (Secondary)
(###)
###
####
Email (Primary)
*
Email (Secondary)
I. Interests
(Information will be shared with the volunteers/mentors working with your Child/Teen/Adult with special needs)
1. How would you explain your Child/Teen/Adult to us?
2. What activities does your child/teen/adult(s) like to do?
*
(Check all that apply)
Dancing
Crafts
Coloring
Basketball
Hula Hoop
Movies
Music
Sports
Other
3. Does your teen/adult work? If so, where and what hours?
*
4. Does your child/teen or adult have any Hobbies: If so, what?
*
5. Any Special Diet Restrictions?
*
6. Any Food Allergies?
*
7. Environmental Allergies?
*
8. Sound Sensitivity? If yes, please explain:
*
9. Do they wear headphones?
*
10. Any medical issues we need to know about?
*
11. Any seizure history? If yes, what do you usually do?
*
12. Any other relevant medical information:
II. Availability
At what times are you interested in having events:
*
(Check all that apply)
Flexible
Weekends
Weekdays
Evenings
Other
What is your family's preferred meeting time?
*
III. Support
Does your child/teen/adult need a Volunteer/Mentor during events or will you bring a caregiver?
*
We pair up our volunteers as much as possible with FUN children/teens/adults – to give parents a break. (Please do what is most comfortable and we will try our best to give support.)
Requesting a F.U.N. Volunteer/Mentor
Will Bring a Dedicated Caregiver
Other
If you selected 'Other' above, please explain:
If you are interested in engaging with a F.U.N. Volunteer/Mentor, do you have any preference on who your Child/Teen/Adult is paired with?
*
No preference
Male Volunteer/Mentor
Female Volunteer/Mentor
Specific Volunteer/Mentor
If you selected 'Specific Volunteer/Mentor' above, please specify who you would like to request by name:
Anything else you would like us to know or that you would like to share about what you would like to get out of the group for your family?
IV. Volunteering Opportunities
Would anyone in your family be willing and able to volunteer to help with the monthly meetings? If so, please list out there names below.
(i.e. planning, preparation/setup, during the meeting, cleanup after the meeting, bring refreshments etc.)
Does anyone in your family have certified or licensed skills and/or training that could be useful during our meetings? If so, please list their names and certifications below.
Registration Agreement
I/we hereby grant F.U.N. permission to use my, and my families, likeness in a photograph, video, or other digital media in any and all of the its publications, without payment or other consideration. Donations to the program are greatly appreciated and allow us to continue to offer meetings to the community. Thank you for any support you are able to contribute.
By checking this box, I certify that I am over the age of 18 and agree to register myself and/or my family as an active member with Families United in Newtown. Registration covers events starting from the date listed on this agreement.
I Agree
If you have any questions, please feel free to call Linda at 203-512-6284
Thank you!
We look forward to seeing you at the next F.U.N. Event!
