SOUL BOWLERS BOWLING PROGRAM

SOUL BOWLERS BOWLING PROGRAM

REGISTRATION FORM - BOWLERO WESTERN BRANCH LANES
Saturday, September 6, 2025 – Saturday, October 4, 2025

BOWLERO WESTERN BRANCH LANES

3101 Lynnhurst Boulevard

Chesapeake, VA 23321

9:30 a.m. to 10:30 a.m.
Parent/Guardian Information:
Parent's Name:

First NameLast Name
Parent's Email:
example@example.com
Parent's Cell Phone:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PLEASE HELP US CONTINUE TO OBTAIN FUNDING BY ANSWERING THE FOLLOWING QUESTIONS. SOME GRANTS REQUIRE DEMOGRAPHIC INFORMATION. THIS IS OPTIONAL AND YOU MAY PUT “N/A”. ALL INFORMATION IS KEPT CONFIDENTIAL AND ONLY STATISTICAL DATA IS SUBMITTED:
What is your Race/Ethnicity?
What city do you live in?*
Participant's Information:
Participant's Name:

First NameLast Name
Sibling's Name:

First NameLast Name
Participant's Gender:

MaleFemaleOther
Sibling's Gender:

MaleFemaleOther
Participant's Date of Birth?

MonthDayYear
Date
Sibling's Date of Birth?

MonthDayYear
Date
Primary Diagnosis:
Primary Diagnosis for Sibling:
Any Secondary Diagnosis:
Any Secondary Diagnosis for Sibling:
Has Participant bowled before?

YesNo
Has Sibling bowled before?

YesNo
Does the participant need someone assigned to them at all times?

YesNoPossibly
Does the sibling need someone assigned to them at all times?

YesNoPossibly
Any behavioral concerns we should be aware of?

WanderingRunningHittingBitingOther
Any behavioral concerns we should be aware of for sibling?

WanderingRunningHittingBitingOther
Any physical concerns or other behavioral concerns?
Any physical concerns or other behavioral concerns for sibling?
Is participant verbal or nonverbal?

VerbalNonverbalSomewhat VerbalSomewhat NonverbalOther
Is sibling verbal or nonverbal?

VerbalNonverbalSomewhat VerbalSomewhat NonverbalOther
Explain how communication is processed for participant?
Explain how communication is processed for sibling?
Can participant follow 1 step directions?

YesNo
Can sibling follow 1 step directions?

YesNo
Photo Consent for Participant and Sibling?*

YesNo
Emergency Contact Name:

First NameLast Name
Emergency Contact Phone:
Emergency Contact relation to participant?
LIABILITY WAIVER: I am aware that participation in the bowling program has some inherent risks and injury can occur. On rare occasions these injuries can be serious. In consideration of my child being allowed to participate in the four-week program. I, the parent/guardian, assume the risk of all injury and agree not to sue Complete The Puzzle, the directors, coaches, assistant coaches, agents, or volunteers for any and all injuries caused by or resulting from participating in the four-week bowling program. By signing this waiver, I also authorize the use of the pictures of the above-named participant to be posted on Complete The Puzzle’s website or advertising media published by the organization.

AGREE
Signature

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Bowling Participant
$35.00 Quantity

Sibling Participant
$20.00 Quantity

Total

$0.00

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SOUL BOWLERS BOWLING PROGRAM

Parent/Guardian Information:

Participant's Information: