Please fill out the following information as completely as possible.
*Required Fields
*Child's First Name:
*Child's Last Name:
*Child's Gender:
*Child's Date of Birth (MM/DD/YYYY):
Has your child ever
attended a Sibshop before?
School:
Grade:
*Parent(s) Name(s):
*Home Address:
*Home Phone:
Alternate Phone:
*Name of sibling with
Down syndrome:
Gender:
What kind of related special education services (e.g., speech, OT, PT, etc) does this child receive?
Other siblings and ages:
What do you hope your child
will gain from our Sibshop?
Any special topics you
would like addressed?
Special needs of your child (food allerigies, health restrictions, etc):
Other information
you feel would make Sibshops a
more enjoyable and educational
experience for your child:
Would your name like to be placed on a list to be distributed to siblings and their families?
Include your phone number?
registration
PLEASE NOTE
- Your family MUST be members of Club 21 for your child to participate inSibshops. See our membership page for more information about joining Club 21.
- Your student/child is not considered registered for these sessions until registration has been RECEIVED. Please pay on-line below, by mailing in your check or on the day of Sibshops.
- Sibshop registration is limited. Registration is on a first come, first served basis.
For more information, please contact Olivia Hinojosa at olivia@clubtwentyone.org.
sibshop
What: Children's Sibshops for brothers and sisters
of children with Down syndrome
Where: Club 21 Learning and Resource Center
Signs will be posted for the appropriate room When: 2nd Saturday of every month from 10-11:30am
Regrets: If you can't make a Sibshop that you have registered for,
please email Olivia Hinojosa 72 hours prior to your session at olivia@clubtwentyone.org. We will be unable to refund or
reassign payments if notice is not provided in the required time.
Parking: Please park on the north side Santa Barbara Street.
LIABILITY WAIVER:
I hereby give my child permission to participate in Sibshops. By submitting this registration I agree to hold Club 21 Learning and Resource Center harmless for any and all liability incurred as a result of my child's participation. Further I grant full permission to use any photographs, viedeotapes, recordings or any other record of this program for the purpose of education and promotion of Sibshops or Club 21.
Please e-sign this by providing your full name and initials below.
*Full Name *Initials
*InitialsPAYMENT INFORMATION
SIBSHOPS ARE NOT VENDORED.
Sibshops cost $15 per session
*Payment information:
*Sessions Attending:
Paying by cash:
Cash payments should NOT be mailed. After filling out this form, please bring cash to the Club 21 office at 539 N Lake Avenue, Pasadena, CA 91101
Paying by check:
After filling out and submitting this form please send a check (payable to Club 21)
Club 21 Attn: Sibshop Registration
539 N Lake AvenuePasadena, CA 91101Paying by PayPal:
Please CLICK ON the option below that are most appropriate for you. Then come back to this page and click Submit.
