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The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

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/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

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/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

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/^((((\+44|0044)\s?\d{4}|$?0\d{4}$?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|$?0\d{3}$?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|$?0\d{2}$?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

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xseyQ3iENQe8FzKpxyjFuqnNbKWTDFzeCwj5b8XG74FdcqIXVn8noZ9Nev

DreamCatchers Registration

Spring 2021 Dates: February 9^th through May 1^st

Virtual

Tuesdays from 6:00-7:00 p.m.

$75 per child

Please complete the form for each child you would like to register.

Participant's name

* must provide value

Preferred name

Date of birth

* must provide value

D-M-Y

Gender

* must provide value

Primary language spoken at home

* must provide value

Medical conditions (check all that apply)

* must provide value

ADHD

ASD

Brain injury

Cerebral palsy

Down syndrome

Deaf/hard of hearing/hearing loss

Blind/low vision/vision loss

Asthma

Diabetes

Heart condition

Hepatitis

Learning disability

Epilepsy/seizure disorder

Mobility impairment

Mental health concern

No disability or health concern

Other

Please describe any additional critical health care concerns associated with the aforementioned list above:

Expand

Any other medical/behavioral concerns we should be aware of? (biting, self-injurious behavior, etc.)

Expand

Allergies: check all that apply

Eggs

Wheat

Peanuts

Tree nuts

Milk

Soy

Penicillin

Other

Has your child experienced trauma or a recent life change?

* must provide value

Yes

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If your child has experienced trauma, please elaborate.

* must provide value

Expand

Will this child or a caregiver need to administer medication during our meeting time?

* must provide value

Yes

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Does this child communicate verbally?

* must provide value

Yes

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What means of expression and receptive communication does this child use? (check all that apply):

* must provide value

Verbal communication

Speech reading

American Sign Language

Signing exact English

AAC device

Other

Which, if any, of the following mobility aids does this child use? (check all that apply):

Manual wheelchair

Motorized wheelchair

Walkers

Standers

Orthotics

Other

Does this child use hearing aids or cochlear implants?

* must provide value

Yes

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Any additional information you would like us to know about this child?

Expand

The following section is to be completed by individuals with a visual disability: What is your degree of blindness?

Total

Light perception

Form perception

Other

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Travel aids:

Cane

Service animal

Other

None

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Please describe any assistive technology this child uses:

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Please indicate this child's preferred alternative font:

Large print

Electronic format

Braille

Other

None

reset

Name of guardian

* must provide value

Relationship to participant

* must provide value

Primary phone number

* must provide value

Primary email address

* must provide value

Street Address

* must provide value

City

* must provide value

County

* must provide value

State

* must provide value

Zip code

* must provide value

Emergency contact information:

* must provide value

Expand

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