Autumn Connection

Autumn Connection
Parent/Guardian Name:

First NameLast Name
Email Address:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Home Address:

Street Address

Street Address Line 2

CityProvince

Postal Code
Learner's Full Name:
Learner's Age:
APSEA Learner Service(s): (Select all that apply)
Accommodation requirements
If other, please specify:
*While we do our best to meet everyone's access needs and provide accommodations, this may not always be possible.
Additional Participants
How many other people will be attending (adults and children):
- 1) Participant Name:
  
  First NameLast Name
- 1) Relationship to Learner:
- 1) Participant Age:
- 2) Participant Name:
  
  First NameLast Name
- 2) Relationship to Learner:
- 2) Participant Age:
- 3) Participant Name:
  
  First NameLast Name
- 3) Relationship to Learner:
- 3) Participant Age:
- 4) Participant Name:
  
  First NameLast Name
- 4) Relationship to Learner:
- 4) Participant Age:
- 5) Participant Name:
  
  First NameLast Name
- 5) Relationship to Learner:
- 5) Participant Age:
- Waiver for Participation
- Parent/Guardian Name:
  (used as your digital signature for this waiver)
- Financial Support
  
  Financial assistance for travel is available to families of learners who qualify for APSEA support.
- Request financial support for travel expenses.
- Comments
- Is there anything else you would like us to know?
- Feedback
- How did you hear about this program?
- If Other for how you found out about this program, please specify
- Should be Empty:

Autumn Connection

Additional Participants

Financial Support

Comments

Feedback