Semi Formal Registration Form - Lola’s Roundtable

X/Twitter

This field is for validation purposes and should be left unchanged.

Will a caregiver/support worker be accompanying the attendee throughout the semi formal?(Required)

Yes

Buddy

A buddy serves as a supportive companion for an individual who might not have someone attending with them.

The buddy’s role includes:

Helping the individual navigate the event, such as locating the bathroom or finding their assigned table.
Encouraging them to participate in activities, like dancing or engaging with others, to ensure
Keeping an eye on their well-being throughout the event, including checking on their comfort and ensuring they remain in good health.
Assisting with practical needs, like making sure they receive the proper dinner or any dietary accommodations they may require.

The buddy is there to ensure the individual feels cared for and has a positive, stress-free experience.

Would your family member like a buddy?(Required)

Yes, they would like a buddy

No, they do not need a buddy

My family member would like their buddy to be:(Required)

Female

Male

No preference

Guardian/Caregiver Contact Information

Guardian/Caregiver Full Name(Required)

First Last

Phone(Required)

Email(Required)

Company Name

Does the attending caregiver/support worker have any dietary restrictions?(Required)

Yes

Please list the attending caregiver/support worker's dietary restrictions:(Required)

Attendee Information

Attendee Full Name(Required)

First Last

Attendee Age(Required)

Behavioural Information

Physical Behaviours(Required)

Yes

No physical behaviours

Verbal Behaviours(Required)

Yes

No verbal behaviours

Please explain physical behaviours:(Required)

Please explain verbal behaviours:(Required)

Flight Risk(Required)

Yes

No verbal behaviours

Please explain flight risk:(Required)

Mobility Information

Please check all that apply.(Required)

Independently mobile

Wheelchair

Walker

Other

Wheelchair(Required)

Please provide more details and specify type of chair below (ex. push chair / electric chair, etc).

Other(Required)

Please provide details below:

Vision and Auditory

Vision(Required)

Good

Visually Impaired (Requires Guidance)

Auditory(Required)

Good

Hearing Impaired (Requires Guidance)

Visually Impaired (Requires Guidance)(Required)

Please provide details below:

Hearing Impaired (Requires Guidance)(Required)

Please provide details below:

Communication

Communication Expressive(Required)

How does your family member communicate to others, ex. verbal, sign language etc? Please provide details below:

Communication Expressive(Required)

How does your family member communicate to others, ex. verbal, sign language etc? Please provide details below:

Communication Receptive(Required)

How does your family member receive communication from others? Provide details below:

Dietary

Dietary(Required)

Eats Independently

Requires Assistance

Allergies

Dietary Restrictions (Dislikes / Should Not Have)

Purée / Minced

Requires Assistance(Required)

Please provide assistance details below:

Allergies(Required)

List allergies below:

Dietary Restrictions (Dislikes / Should Not Have)(Required)

Provide dietary restrictions details below:

Purée / Minced(Required)

Please explain texture below:

Getting Ready

Please select glam options needed (check all that apply):(Required)

Make up and hair will be available for free from 3:45pm - 4:45pm at the Leamington Lebanese Club

Make Up

Hair

Glam options are not needed

Table Seating

Are there attendees your family member would like to sit with?(Required)

Yes

No seating preference

Names of attendees your family member would like to sit with:(Required)

Please enter any names of attendees your family member would like to be sat with. If names aren't provided, your family member may not end up at a table with friends.

Ticket Purchase

Attendee Ticket

Price:

Caregiver/Support Worker Ticket

Price:

Purchase Ticket Options

Select how you would like to purchase tickets.(Required)

Credit Card

E-Transfer

Cash

Credit Card Information

*Please send E-Transfer to semiformal@lolasroundtable.com.

Cash can be delivered to:

Lola's Roundtable
69 Talbot St N, Essex, ON
*Can leave in mailbox with name of attendees

Total Amount:

Would you like a receipt?(Required)

Yes

Name of person requiring receipt(Required)

First Last

Email address to send receipt to(Required)

6 + 3 =(Required)

(After entering the correct answer in the box above, the Submit button will appear.)

Semi Formal Registration

Register an Individual for Semi Formal

Buddy

Guardian/Caregiver Contact Information

Attendee Information

Behavioural Information

Mobility Information

Vision and Auditory

Communication

Dietary

Getting Ready

Table Seating

Ticket Purchase

Purchase Ticket Options

Contact Us

Payment Methods

Additional Info

Sign Up for Our Newsletter