EVENT REGISTRATION

Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Birthday *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender *

Male

Female

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Is support needed in the restroom? *

Yes

No

If yes, please indicate what areas assistance is required in. *

Tolieting

Wiping

Clothing Management

Washing Hands

Individual is independent in all restroom-related areas.

Is support needed for eating? *

Yes

No

Describe the requested level of support for JoyKC nights: *

We do our best to provide one-on-one volunteers for those who may benefit from this level of support and/ or engagement. But, you are the expert here. Tell us how we can BEST serve this individual.

One-on-one Buddy requested

Does not need or want one-on-one Buddy

If there's one available, great. If not, great!

I give JoyKC permission to use photographs of me for purposes including publicity, advertisement, illustration, social media, and web content. *

Yes

No

Please type your name to electronically sign this form. *

First Name

Last Name