Parent/Guardian Name (or Self, if Independent) *

First Name

Last Name

Phone

(###)

###

####

Would you like to be added to our private Facebook group?

Yes, please send an invite!

No, not right now.

Preferred Method of Contact for Event Updates

Email

Phone Call

Text

What type of activities do you enjoy most? (Check all that apply)

Social events (bowling, movie nights, parties, etc.)

Life skills (cooking, art workshops, budgeting, etc.)

Sports & recreation (adaptive fitness, swimming, etc.)

Community involvement (volunteering, outings, advocacy events, etc.)

How did you hear about the 321 Group?

Social Media

Word of Mouth

Healthcare Provider

Event