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OMA Registration - Winter Session 2023 - Saturdays
Saturdays, January 14 - March 4, 10:30-11:30 am
Participant Name
*
First Name
Last Name
Caregiver Name
*
First Name
Last Name
Caregiver Email
*
Verify Email
*
Caregiver Home Phone
*
Caregiver Mobile Phone
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Emergency Contact (other than Caregiver)
*
First Name
Last Name
Emergency Contact Phone
*
Please tell us about the Participant
*
To better prepare our volunteers to work with your loved one, we would like to know about the participant’s fine motor skills, communication skills, physical limitations, and the comfort level outside of their home.