Pamper My Baby Registration

Registration OPEN for May 22nd & June Workshops!

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

Pamper My Baby Registration – May & June 2025

Childcare will be available until it is at capacity.

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

Workshop Registering For * May 22nd, 10:00 am – 1:00 pm, 12125 Day St. E 307, Moreno Valley, CA 92557June 6th, 10:00 am – 1:00 pm, 3590 Tyler St., Suite 101, Riverside, CA 92503June 11th, 10:00 am – 1:00 pm, 805 W. Second St., Suite C, San Bernadino, CA 92410

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:

Have you previously attended a Pamper my Baby Workshop? * NoYes

*

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.

*

I ACKNOWLEDGE THAT PARTICIPANTS WILL ONLY BE GIVEN A 15 MINUTE GRACE PERIOD AND IF ARRIVING AFTER GRACE PERIOD, PARENTS WILL NOT BE ABLE TO PARTICIPATE IN OUR WORKSHOP AND WILL HAVE TO REGISTER FOR ANOTHER ONE.

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