Name *

Parent Name

First Name

Last Name

Phone

(###)

###

####

Child/Children's name(s)

First Name

Last Name

Child/Children's age(s) *

Under 2

2-4

5-7

8-10

11+

My child has the following diagnosis(es), or we are in the evaluation process for *

This helps us understand the needs of the group as we plan meet ups and content. Please share as you are comfortable.

Autism

Sensory Processing Disorder

Other Developmental Delay

Speech Delay

Oppositional Defiance Disorder

ADD/ADHD

Pervasive Developmental Disorder (PDD)

I do not wish to disclose

Other

I am interested in *

Playground meet ups

Group Outings

Online Community

Parent Workshops/Resource Sharing

In-person Community

I prefer the following time slots (check all that apply) *

I am not in the Baltimore area/I do not plan to join in-person events

Saturday mornings

Saturday afternoons

Sunday mornings

Sunday afternoons

Friday evenings

No preference

My child's/family's priorities for this kind of experience are (choose top three) *

Building friendships with like-peers

Gaining knowledge from like-families

Exposure for my child

Variety of activites

Navigating new experiences with support from others

Safe play experiences

Other