APSEA’s Kick Off to Summer
Parent/Guardian Name:
*
First Name
Last 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
City
Province
Postal Code
Learner's Full Name:
*
Learner's Age:
*
EST (DHH or BLV)/Itinerant Teacher Name:
APSEA Service:
*
Please Select
Supporting children and youth who are Blind and Low Vision
Supporting children and youth who are Deaf and Hard of Hearing
Supporting children and youth who are Blind and Low Vision, Deaf and Hard of Hearing
Autism in Education support
Additional Participants
How many other people will be attending (adults and children):
*
Please Select
0
1
2
3
4
5
1) Additional Participant
1) Participant Name:
First Name
Last Name
1) Relationship to Learner:
*
Please Select
Parent/Guardian
Sibling
1) Participant Age:
*
2) Additional Participant
2) Participant Name:
First Name
Last Name
2) Relationship to Learner:
*
Please Select
Parent/Guardian
Sibling
2) Participant Age:
*
3) Additional Participant
3) Participant Name:
First Name
Last Name
3) Relationship to Learner:
*
Please Select
Parent/Guardian
Sibling
3) Participant Age:
*
4) Additional Participant
4) Participant Name:
First Name
Last Name
4) Relationship to Learner:
*
Please Select
Parent/Guardian
Sibling
4) Participant Age:
*
5) Additional Participant
5) Participant Name:
First Name
Last Name
5) Relationship to Learner:
*
Please Select
Parent/Guardian
Sibling
5) Participant Age:
*
End of Form
Waiver for Participation
*
I acknowledge that I understand this is not a supervised event. APSEA staff will be present, but I am solely responsible for the safety of my family members.
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.
Yes
Comments
Is there anything else you would like us to know?
Feedback
How did you hear about this program?
*
Please Select
APSEA Website
Facebook
X (Twitter)
APSEA Email
APSEA Event Postcard
APSEA Service Delivery Team Meeting
APSEA Specialist
Word of Mouth
Other
If Other for how you found out about this program, please specify
Register for Event
Should be Empty: