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Virtual Bingo Registration Form

Virtual Bingo is held every Friday at 7:00 PM. It is open to individuals with Down syndrome or other intellectual and developmental disabilities ages 16+.

This program is provided free to families by the Down Syndrome Association of Delaware.

Please complete the following registration form to reserve your spot for Virtual Bingo.

Questions? Contact Jess at jess@dsadelaware.org.

Thank you!

Participant Contact Information

Participant Name

First Name

Last Name

Participant Email

Verify Email

Participant Phone

Participant Date of Birth

(mm/dd/yyyy)

Does the participant have Down syndrome?

Yes

What diagnosis does the participant have?

Are there any health or behavioral concerns for the participant that we need keep in mind?

Please provide the following information for one adult support contact.

Adult Support Contact

Support Contact Name

First Name

Last Name

Support Contact Email

Verify Email

Support Contact Phone

Type of Adult Support

Parent

Guardian

Other Support Person

I understand by clicking SUBMIT I am registering for Exercise classes.

Yes, I understand.