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Muhsen ILMCON Registration 2025

Participant Information

Participant's First Name

Participant's Last Name

Participant's Age

Participant's Gender

Participant's Disability

Caregiver's Contact Information

Caregiver's First Name

Caregiver's Last Name

Caregiver's Phone Number

Caregiver's Email

A confirmation email will be sent to this email after submitting this form.

Number of Family Members Attending the Conference

Emergency Contact Information

Emergency Contact's First Name

Emergency Contact's Last Name

Emergency Contact's Phone Number

Emergency Contact's Relationship to Participant

Additional Information about the Special Need Participant

Will you need respite for your special need loved one?

Do they use an assistive device?

What is their best mode of communication?

What are their preferred activities?

What do they find upsetting?

What are the challenging behaviors we are likely to see when they are upset?

How should one calm a negative behavior?

Is the participant able to use the restroom on their own?

Are any of these accommodations needed:

Is there any additional information you would like to share?

Disclaimers

Media

I give permission to photograph, film, or videotape my special need loved one. All pictures/recordings can be legitimately used without any limitation or reservation for reasons of safe and appropriate purposes such as publicity, illustration, advertising, and Web content.
Media

Release, waiver and discharge

I understand that sending my child to partake in MUHSEN and Institute of Knowledge (IOK)'s respite care is my decision. I hereby assume all responsibility for any and all risk of property damage or bodily injury that I may sustain while participating in any activity of any nature. Further, I, for myself and my heir, executors, administrators and assigns, hereby release, waive and discharge Muhsen & IOK and its officers, directors, employees, agents and volunteers of responsibility.
Release, waiver and discharge