Early Intervention Playdate Registration

Join us on Saturday, July 23rd at 10:30 a.m. for a virtual workshop.

Family Information
Parent's Name * Required
First Last
Child's Name * Required
First Last
Child's Date of Birth * Required
MM slash DD slash YYYY
Parent's Email * Required
Enter Email Confirm Email
Number of Adults Attending
Number of Siblings Attending
List
Name of Sibling Attending Age of Sibling

Click the + on the right to add more siblings.
Regional Center
Race/Ethnicity
Note: this information is for reporting purposes only and will remain confidential.
- Asian
- Black (non-Hispanic)
- Hispanic
- Native American
- Native Hawaiian or Other Pacific Islander
- White (non-Hispanic)
- Bi-Racial
MEDIA RELEASE * Required
Permission is hereby given to WAYFINDER FAMILY SERVICES® to use audio, video recordings, photographic and electronically created images of the camper noted in this application for public view, including publications, websites or social media sites. Usage of any images or audio is without compensation to said person or to the undersigned on his/her behalf, or individuality. On occasion, specific campers are identified for profile stories used in grant applications and reports, publications, websites or social media sites. Permission is hereby given to WAYFINDER FAMILY SERVICES® to publish this camper’s story in grant applications and reports, publications, websites or social media sites, with related quotes, after verbal and/or written approval of that story has been granted by said person or by the undersigned on his/her behalf or individuality.
- I have read the media release and agree to all its contents.
Electronic Signature * Required

Name of Sibling Attending	Age of Sibling

Program Areas

Family Information