Below you will find an online form to fill out and submit to us. Thank you. Liberty Client Sign Up Client's Name* First Last Please enter your child's full name.Male/Female*MaleFemaleAge*Date of Birth* Ethnicity (for reporting purposes only)* Caucasian Black or African American Asian American Hispanic Native American Mixed Descent Please check the box that represents the member's ethnicity.Disability*SchoolEmployer (if any)Parents/Guardian Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home Phone*Cell Phone Mom*Cell Phone Dad*Email* Name & Phone Number for Alternate Contact*Tell us about the participant (strengths, likes, dislikes, favorite activities, hobbies, sports, etc.)*Tell us about behaviors or fears we need to know about when participating in group activities*Tell us how we can best support your child when exhibiting behaviors*Tell us about safety concerns we need to know about when participating in group activities*What activities would your child enjoy?*Any allergies or medical conditions we should be aware of?*Any other information which would be helpful to ensure participation, enjoyment and safety?*Waiver Statement* I have read and understand the Waiver Statement below. I hereby authorize Inclusion Connections to give consent for any and all necessary emergency medical and first aid care for my child. I do hereby release and hold harmless Inclusion Connections Inc., its employees and representatives from liability, claims or causes of action for any illness/injury to person or damage to property resulting from, or occurring during Inclusion Connections, Inc. sponsored activities. I also understand that photos from the activities may be used in printed materials for marketing purposes, on the Inclusion Connections, Inc. website or Facebook page and in future print materials. I give my permission to release any photos taken.