BEAM Workshop Registration

Confidence in the Kitchen Workshop

Registration Form

Thank you for your interest in participating in the Mission BEAM program’s “Confidence in the Kitchen” workshop on May 4, 2024. We encourage parents and students to review and complete this form together.

Paren/Guardian Name *

Student's First Name *

Student's Last Name *

Student's Birth Date *

Month

Day

Year

Student's Grade *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Parent/Guardian Phone *

(

Area code

)

Prefix

Number

Student's Phone

(

Area code

)

Prefix

Number

Parent/Guardian Email Address *

Student's Email Address

How did you hear about this workshop? *

RSB

If "Yes" who is their counselor?

If "No" are you and your student interested in opening a case and/or learning more about RSB?

Materials

Resources and supplemental materials will be provided during the workshop. Please let us know which method is easiest for the student to access these materials. *

If "Large Print" is selected, what is the font size the student prefers?

Please give a brief description of the student’s experiences in the kitchen? *

What are the student’s goals/expectations for cooking independently? *

What are the parent/guardian’s goals/expectations for your student when it comes to cooking independently? *

Does the student and/or parent/guardian have any questions that you hope will be addressed during this workshop? *

In the event of an emergency.

Contact Person *

Relationship to student *

Phone *

(

Area code

)

Prefix

Number

Does the student have any medical conditions? *

If "Yes" please explain medical conditions

Does the student take medications? *

If "Yes" please list all medications

Will the student need to take any medication during the workshop? *

If "Yes" please provide workshop medication details

Lunch will be provided for students during the workshop. Does the student have any food allergies or special dietary restrictions? *

If "Yes" please explain dietary restrictions

Is there anything else you and your student would like us to know about him/her? *

Permission & Release Form

Does the Program Coordinator have permission to seek medical attention for the student in the event that a medical emergency occurs? *

During this workshop photos may be taken and some or all of the activities may be recorded. These photos and recordings will be used for future education, documentation, and advertising purposes. Please answer the following questions to indicate you and your student’s preferences.

Thank you for completing the form. By electronically signing this form you and your student are stating that you have read and understand the information above.

Parent/Guardian Signature *

By signing your name electronically, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this Form.

Student Signature *

By signing your name electronically, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this Form.

Date *

Month

Day

Year

BEAM Workshop Registration

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