Registration | Refocus Behavior

Tell Us About the Child You'd Like to Enroll

First & Last Name

Gender

Birthday

Month

Day

Year

Tell Us About You

Mother's Name

Father's Name

Preferred Email

Primary Phone

Alternate Emergency Contact

Contact Name

Phone

Tell Us About The Brother or Sister with Special Needs

Name

Age

Gender

Name or description of disability, diagnosis, or health concern

Tell Us About Their Other Siblings

How many other siblings besides these two?

Tell Us Additional Information

What do you hope your child will gain from our Sibshop*? Are there any particular topics you would like addressed?

Does your enrolled child have any special needs, food allergies, or other health restrictions of their own that we should know about?

Please provide any other information that you feel would make Sibshops a more enjoyable and educational experience for your child.

Payment

The cost to attend a Sibshop is $35, which includes all program materials and lunch. Scholarships may be available based on sponsor participation and will be awarded in the order registrations are received. Final costs and invoices will be sent to parents 7–10 days before the event.

Authorization (form cannot be submitted without this)

I hereby give my child permission to participate in Sibshops. I also agree to hold Refocus Behavior harmless for any and all liability incurred as a result of my child’s participation. Further, I grant full permission to use any photographs, videotapes, recordings or any other record of this program for the purpose of education and promotion of Sibshops.

Our staff will call you upon receipt of this completed form to go over final details, answer any additional questions you may have, and discuss payment.