Zip Code*

County*

By attending this event, I voluntarily release and hold harmless Autism Moms of Houston, its volunteers, sponsors, and event organizers from any liability, claims, or demands arising from any injury, illness, or harm that may occur to me or my family during the event. I acknowledge that Autism Moms of Houston is not responsible for any accidents, injuries, or incidents that may take place at the event.*

I understand that childcare will not be provided during the event, and I am fully responsible for supervising my child(ren) at all times while attending. I agree to ensure my child(ren)’s safety and well-being throughout the event and understand that Autism Moms of Houston and its volunteers are not responsible for child supervision.*

Photo/Video Release Permission: I grant permission to Autism Moms of Houston (AMoH) to take photographs and videos of me and my family during the event. These images may be used for promotional purposes, including but not limited to social media, newsletters, and event recaps. I understand that these images will be used in a respectful and positive manner to showcase our community’s events and successes.*

Total number of people in your family coming with you?*

Total Number of Children Attending:*

Total Number of Adults Attending:*

Total number of autistic individuals or individuals with special needs attending in your group.*

For Grant Purposes: Please answer the following question. What is your family’s household income?*

Would you like to receive text updates about future events from Autism Moms of Houston? If so, please provide your phone number below.

What is your family’s primary language spoken at home?*

What is your family’s race/ethnicity? (Select all that apply)

The information provided by you helps us serve our community and ensure we have enough refreshments for everyone. If you cannot attend, please notify us at contact@autismmomsofhouston.org. Thank you!*