Fall Harvest Fest - Group Home

Fall Harvest Fest Registration

Saturday 9/19, 10:30AM - 12:30PM: Dr. Davies Farm, Congers
Group Home Contact
Please enter the name and contact information of the person completing this registration form.
Group Home Contact First Name
Group Home Contact Last Name
Group Home Contact's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Home Contact's Email
example@example.com
Group Home (or Agency) Name
Group Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Attendee and Caregiver Registration

Each OPWDD eligible individual/attendee may bring up to ONE caregiver/chaperone for free. If an eligible individual requires supervision by more than one caregiver, please contact RCDMH at (845) 364-2391 for instruction on how to register and pay for that additional person.
How many OPWDD Eligible individuals will be attending:
The primary Caregiver/Chaperone will be used as the contact for all communications, including last minute updates.
Primary Chaperone/Caregiver Name

First NameLast Name
Primary Chaperone/Caregiver Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Chaperone/Caregiver Email Address
example@example.com
Eligible Individual/Attendee 1
Name

First NameLast Name
Age
Lives in an OPWDD Residence
Accessibility Seating Need
Eligible Individual/Attendee 2
Name

First NameLast Name
Age
Lives in an OPWDD Residence
Accessibility Seating Need
Will Attendee #2 be accompanied by a different caregiver or the same primary chaperone?
Caregiver/Chaperone Name

First NameLast Name
Caregiver/Chaperone Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Caregiver/Chaperone Email Address
example@example.com
Eligible Individual/Attendee 3
Name

First NameLast Name
Age
Lives in an OPWDD Residence
Accessibility Seating Need
Will Attendee #3 be accompanied by a different caregiver or the same primary chaperone?
Caregiver/Chaperone Name

First NameLast Name
Caregiver/Chaperone Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Caregiver/Chaperone Email Address
example@example.com
Eligible Individual/Attendee 4
Name

First NameLast Name
Age
Lives in an OPWDD Residence
Accessibility Seating Need
Will Attendee #4 be accompanied by a different caregiver or the same primary chaperone?
Caregiver/Chaperone Name

First NameLast Name
Caregiver/Chaperone Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Caregiver/Chaperone Email Address
example@example.com
Eligible Individual/Attendee 5
Name

First NameLast Name
Age
Lives in an OPWDD Residence
Accessibility Seating Need
Will Attendee #5 be accompanied by a different caregiver or the same primary chaperone?
Caregiver/Chaperone Name

First NameLast Name
Caregiver/Chaperone Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guest/Caregiver Email Address
example@example.com
Who
Total
If you do not see a SUBMIT button, please check the number of names entered above. The total number of attendees must match the number of names entered (individuals AND chaperones) to submit this form.
Registration Attestation
Acknowledgement
You will receive an email confirmation approximately one week after submission that will confirm your registration has been accepted.

*If you have dietary restrictions that require our attention or any questions/concerns please contact RCDMH at (845) 364-2391 or (845) 364-2392.
Should be Empty:

Fall Harvest Fest Registration

Group Home Contact

Attendee and Caregiver Registration

Eligible Individual/Attendee 1

Eligible Individual/Attendee 2

Eligible Individual/Attendee 3

Eligible Individual/Attendee 4

Eligible Individual/Attendee 5

Registration Attestation