Pamper My Baby Registration

This registration is for parent participants only. If you would like to learn more information about resources for your organization please email us.

Childcare will be available until it is at capacity.

Workshop Registering For

Do You Need an Interpreter For This Workshop?

If Yes, What Language?

Name of Parent / Caregiver Participating

First

Last

Street Address

City

County

Zip Code

Phone

Email

Languages Spoken in the Home

English

Spanish

Deaf / Hard of Hearing

Other

Ethnicity

Child’s Name (0 – 4 years old)

Child's Name (0 – 4 years old)

First

Last

Child’s Date of Birth

Child’s Size Diaper / Pull-up

Child’s Gender

How Many Children in the Home Ages 0-4?

What Are The Diaper Sizes For The Additional Children?

Is Your Child Potty Trained?

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

Would You Describe Your Child / Children as Sociable?

Does Your Child Have Behaviors That You Are Concerned About?

If So, Please Provide Specifics

Do You Meet the Income Qualifications?

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

Are you bringing your child to the event

If so, do you need childcare?

How did you find out about the event?

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

Are you insured by IEHP?

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 SOMEONE CHILDREN MAY HAVE ALLERGIES THEREFORE WE ASK THAT YOU RESTRAIN FROM THE BRINING SNACK 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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Registration Open for May Workshops!

Send questions to pmb@chasing7dreams.org

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