Pamper My Baby Registration

Childcare will be available until it is at capacity.

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

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 many children will be attending childcare?

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?

Member ID number:

Is your child a Regional Center client?

UCI number:

Have you previously attended a Pamper my Baby Workshop?

Are you bringing your child/children to the event?

how many children will be requiring childcare? *Note: children less than 1 years old cannot attend childcare

Will your child require diapers?

Select diaper size for primary child in need

Select diaper size for one sibling

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. IF YOU ARE EXPECTING TO ARRIVE A FEW MINUTES LATE, WE KINDLY ASK THAT YOU CONTACT THE COORDINATOR OR SEND AN EMAIL TO INFORM US. PARTICIPANTS WHO DO NOT REACH OUT AND OR ARRIVE 15 MINUTES AFTER THE START TO THE PROGRAM, WILL NOT BE LET INTO THE WORKSHOP. NO EXCEPTIONS.

By checking this box and initialing on this line, I as a participant involved in Chasing 7 Dreams programs accept that I amy be photographed or videotaped. I also accept that these images may be used for educational, promotional, marketing, training, or research purposes by staff members of Chasing 7 Dreams. I understand, participate, and agree that I and my child (if applicable) whom is under the age of 18 years old to be photographed or videotaped and is given the right to have access to photos or videos if desired.

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July 29th and August workshops are OPEN

Please email pmb@chasing7dreams.org to be waitlisted.