Register for Child Care           

    Child Care Needed        

    Which event do you need child care?
    None Autism: Empowerment Strategies for Parents

    Number of Children   

    Name(s) of Children  

    Ages of Children       

    Special Needs      
    none

    Emergency Contact Information

    Your Name:    

    Emergency Phone Number:   
(Cell Phone preferred for during event contact purposes)

    Regular Contact Phone:       
(We will contact you to confirm registration)

    Other Possible Contact Information
    none