Pamper My Baby Registration

Registration OPEN December Workshops!

To Register for Parent Check-in, contact pmb@chasing7dreams.org.

Email pmb@chasing7dreams.org to be added to registration for September 28th.

Pamper My Baby Registration – November & December 2024

Childcare will be available until it is at capacity.

Available diaper sizes from 0 to 4T/5T only.

Workshop Registering For * December 5th, 10:00am – 1:00pm, 12353 Mariposa Rd. Ste. D1, Victorville, CA 92395December 11th, 5:00pm – 8:00pm, via Zoom (San Bernadino & Riverside County Residents ONLY)

Do You Need an Interpreter For This Workshop? * YesNo

If Yes, What Language?

Name of Parent / Caregiver Participating *

Name of Parent / Caregiver Participating

First

First

Last

Last

Street Address *

City *

County

Zip Code *

Phone *

Email *

Languages Spoken in the Home *

English

Spanish

Deaf / Hard of Hearing

Other

Ethnicity * Black / African AmericanAsianWhiteHispanic / LatinoNative Hawaiian or Pacific IslanderAmerican Indian or Alaskan NativeOther

Child’s Name (0 – 4 years old) *

Child's Name (0 – 4 years old)

First

First

Last

Last

Child’s Date of Birth *

Child’s Size Diaper / Pull-up * Newborn1234562T/3T3T/4T4T/5T

Child’s Gender * MaleFemale

How Many Children in the Home Ages 0-4?

What Are The Diaper Sizes For The Additional Children?

Is Your Child Potty Trained? * YesNo

Would You Describe Your Child as Verbal, Limited Language, or Nonverbal? * VerbalLimited LanguageNonverbal

Would You Describe Your Child / Children as Sociable? * YesNo

Does Your Child Have Behaviors That You Are Concerned About? * YesNo

If So, Please Provide Specifics

Do You Meet the Income Qualifications? * YesNo

How is Your Child Doing (General Health and/or Mood)? *

Are you bringing your child to the event * YesNo

If so, do you need childcare? YesNo

How did you find out about the event? * Physical Flyer/PosterEmail InviteSocial Media PostWebsiteWord of MouthOther

If “other” how did you find out about the event?

Are you insured by IEHP? * NoYes

Member ID number:

Is your child a Regional Center client? * YesNo

UCI number:

*

I UNDERSTAND THAT FOOD WILL NOT BE PROVIDED FOR CHILDREN. PARENTS ARE EXPECTED TO BRING A SNACK AND BEVERAGE FOR THEIR CHILDREN. PLEASE BE MINDFUL THAT SOME CHILDREN MAY HAVE ALLERGIES THEREFORE WE ASK THAT YOU RESTRAIN FROM THE BRINGING SNACKS FOR THE MOST COMMON ALLERGY (I.E. PEANUTS).

*

I ACKNOWLEDGE THAT MY ATTENDANCE IS REQUIRED FOR THE ENTIRE WORKSHOP. THE DIAPERS AND DEVELOPMENTAL TOY WILL BE DISTRIBUTED AT THE END OF THE WORKSHOP. THERE ARE NO EXCEPTIONS. PLEASE PLAN ACCORDINGLY.

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Send questions to pmb@chasing7dreams.org