HighPointe Services - Visitation Registration

Sign Up Form

Exceptional Kids is a free monthly kids club for children with disabilities and their families. Each month has a fun theme with games, activities, and food in a welcoming environment.

Family Contact Information

Parent/Guardian First Name

Parent/Guardian Last Name

Email

Phone Number

Participant Information

Child's First Name

Child's Last Name

Grade

Gender

Tell us anything that will help us serve your child best (Ex: Disability/Diagnosis)

Siblings Name and Age (Ex: John - Brother- 10)

Emergency / Safety

Emergency Contact Name

Emergency Contact Number

Photo Release: We may take photos during the event for nonprofit promotion. Check if you are or aren't okay with photos being taken.

Yes

No

Waiver/Consent

Waiver Signature

< Back

Next >

Submit

Sign Up Form

Family Contact Information

Participant Information

Emergency / Safety

Waiver/Consent

About

What we do

Support Us