SOUL BOWLERS

SOUL BOWLERS

REGISTRATION FORM - Lucky Strike Western Branch Lanes
Saturday, October 17, 2026 – Saturday, November 21, 2026

LUCKY STRIKE 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:

Other
Sibling's Gender:

Other
Participant's Date of Birth?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sibling's Date of Birth?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Diagnosis:
Primary Diagnosis for Sibling:
Any Secondary Diagnosis:
Any Secondary Diagnosis for Sibling:
Has Participant bowled before?
Has Sibling bowled before?
Does the participant need someone assigned to them at all times?
Does the sibling need someone assigned to them at all times?
Any behavioral concerns we should be aware of?

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

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

Other
Is sibling verbal or nonverbal?

Other
Explain how communication is processed for participant?
Explain how communication is processed for sibling?
Can participant follow 1 step directions?
Can sibling follow 1 step directions?
Photo Consent for Participant and Sibling?
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.
Signature
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Bowling Participant
$30.00 Quantity

Sibling Participant
$15.00 Quantity

Total

$0.00

Payment Methods

Debit or Credit Card

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Parent/Guardian Information:

Participant's Information:

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Payment Methods

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